Aoife Johnston was in 'death trap' ED as inquest returns verdict of medical misadventure
Aoife Johnston's parents are devastated after their daughter passed away due to critical errors in her treatment at University Hospital Limerick. According to them, the emergency department was a hazardous environment that tragically led to a painful and distressing end for their beloved child. It was a terrible experience that they would never wish on anyone.
Carol and James Johnston expressed their desire for their daughter to have a positive memory, not as the girl who passed away on a hospital trolley. They wished for her to be remembered as a cheerful and carefree person who attended school and worked summer jobs.
"We adored our charming teen daughter and our little one just as much as her siblings did," they expressed.
After subjecting to four days of distressing proof during Aoife's inquest, John McNamara, the Limerick Coroner, concluded that her demise was due to medical misadventure as a result of contracting sepsis from meningitis.
According to Mr. McNamara, he had no choice but to agree with the proposed verdict put forward by Damien Tansey, who is the senior counsel and solicitor representing the Johnstone family. The legal representatives for HSE/ULHospitals Group and hospital management did not object to this verdict.
The coroner stated that mistakes and chances for improvement existed in the way Aoife was taken care of.
He stated that communication was lacking in different parts of her treatment.
The coroner stated that he was worried about the excessive amount of people living in Limerick due to his connection to the area. Nevertheless, he acknowledged that there were efforts underway to address this issue.
Aoife, who is 16 years old, was taken to the University Hospital Limerick by her parents just three days prior to Christmas in 2022. This came about after a general practitioner expressed concerns that she was experiencing a decline in her health due to sepsis.
During the inquiry, it was mentioned that hospitals must provide necessary medical assistance to individuals affected by sepsis in a time span of 10 to 15 minutes.
Nevertheless, Aoife was not given priority by UHL for more than an hour.
Even though Aoife was classified as a patient with sepsis, she had to wait for a period of 12 hours before being examined by a doctor.
Aoife experienced severe symptoms such as vomiting a green-colored substance, excruciating pain in her leg, and feeling dizzy and feeble. However, she endured a lengthy period of more than 15 hours to obtain antibiotics, which could have potentially been a lifesaver as reported.
Her parents indicated that she was placed in a storage area at the emergency department because of the constant influx of patients, leaving no other available space.
The inquest heard that James, the father of the girl, was in tears when he shared how he pleaded with the staff to assist his daughter.
Several other patients were lobbying for Aoife, but she was not attended to promptly.
The medication that she required was easily accessible, but due to the inadequate number of workers and excessive number of patients at UHL, the employees were late in administering it to her.
Her mind enlarged and she never recuperated.
According to Mr Tansey, by the time she received the antibiotics, it was too late to revive her and she had passed the point of recovery.
During the weekend that Aoife unfortunately passed away, Dr. Jim Gray was the only consultant for emergency medicine available. However, he did not need to be physically present at the hospital. During the inquest, Dr. Gray expressed his concerns about the emergency department. He described the situation as a "death trap" on the night that Aoife passed away and stated that the department still presents a dangerous situation five years later.
Dr. Gray expressed worry for the patients who come to the ED today. Although there have been some advancements at UHL, he still believes that it is a risky place to be in.
He stated that the number of beds available was inadequate to cater to the high number of patients seeking medical treatment. Additionally, there was only one emergency department specialist available for consultation during weekends and away from the hospital premises.
He expressed gratitude that the majority of the hospital's urgent cases occur during daytime hours instead of nighttime, when there is a lack of staff available.
According to him, there has been an increase in the number of employees since Aoife passed away, and plans to prevent overcrowding are being put into action. However, these measures are not being executed fast enough as per his opinion.
He said to the coroner that Aoife Johnston had no opportunity.
He repeated that Aoife Johnston had no possibility because the ED and the system fell short in supporting her.
The setting was non-functional and went further than merely urgent - it disregarded people's basic human rights and was abusive.
During questioning from Mr. Tansey, Dr. Gray acknowledged that he had turned down a nurse manager's request to be present in the ED on the night Aoife came in.
During the inquest, he stated that consultants who are not physically present at the ED during the weekends, like him, would typically not come back in response to overcrowding as it is a common occurrence.
He repeated that he got a phone call on the evening regarding the increasing problem of overpopulation, but nobody informed him about Aoife.
Dr Gray expressed that he was extremely tired when he received the phone call. He clarified that every time he was notified of overcrowding, he was unable to attend as he was physically exhausted. Additionally, he emphasized that the situation was continually overcrowded.
You have competent employees operating in an inadequate setting. Although there was a leader in charge, unfortunately, the leader was unable to manage the challenging circumstances.
Almost 200 patients were crammed into the corridors of the ED's Zone A, with only a single nurse and doctor responsible for their care.
According to Dr. Gray, he had already been to the hospital that day and departed at 3 pm. It turns out that it was two hours before Aoife showed up.
He mentioned that he was available on-call and providing telephone support to the employees, also managing calls from three regional clinics that specialize in injuries situated in Limerick, Clare and north Tipperary throughout the day.
According to Mr Tansey, two top-ranking physicians, who were registrars, were attending to a surge of patients with fractures in the Resus room adjacent to the Emergency Department. However, this area was also inundated with patients.
But it is said that they refused to check on Aoife even after a nurse tried three times to get them to investigate her.
Dr Mohammed Hassan and Dr Muneeb Shadid both stated in the investigation that they could not remember being requested to examine Aoife.
According to the blog, Nurse Ciara McCarthy made an attempt to seek assistance for Aoife, but she was instructed to keep administering fluids and paracetamol to her. However, Mr. Tansey remarked that the effect of the treatment was practically useless, as it was equivalent to giving Aoife smarties.
In the blog, Mr. Tansey mentioned that a registrar had stated that the fluids were of equal or greater importance than the necessary antibiotics that Aoife needed. Mr. Tansey found this statement to be ridiculous and unworthy of consideration.
Although Dr Gray recognized that the number of non-consultant hospital doctors at UHL had risen from 25 to 47, he cautioned that UHL remains a hazardous environment.
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During the investigation, the advisor stated that the current Emergency Department was considered to be the latest and most advanced when it was introduced in the year 2017. Nevertheless, as per his judgment, it is no longer suitable for its intended use.
According to Dr Gray, the emergency departments that operated non-stop for 24 hours in north Tipperary, Clare and St John's Hospital in Limerick were shut down in 2009 and reorganized into the University Hospital Limerick (UHL). However, he explained that UHL was not given the necessary beds to effectively handle the changes that were made.
He mentioned that there is no Model 3 hospital in the Mid-Western region. This type of hospital would have a 24/7 emergency department to enhance the UHL's Model 4 status. Additionally, it would be the sole 24/7 emergency department serving a population of 425,000 people.
According to him, the release of two blocks with 96 beds each is a positive action, but it does not suffice.
When questioned once more regarding his choice to not show up at the Ed that evening, he repeated that he had no knowledge of Aoife being present. He stated firmly that he was never approached for counsel or requested to go to the ED regarding Ms. Johnston.
According to Dr. Gray, it is evident that there is an enormous amount of overcrowding in the ED during the night.
The individual mentioned that the emergency department was facing a double danger due to the insufficient number of beds and staff as well as an increase in patients on that particular night.
The Department was crowded with patients lying on trolleys, filling up all the empty areas and obstructing doorways, bathrooms, and hallways.
The junior doctor who was tasked with taking care of 191 patients, including Aoife, was praised for his "excellent" efforts.
Dr. Gray informed the nurse who requested him to come back to the ED that he had already worked there earlier that day. He also mentioned that he would be returning to the hospital on the following Sunday morning.
Dr. Gray told Mr. Tansey that bringing in an additional individual, such as a consultant, may not have had the significant impact that he anticipated.
He stated that the only times he might have to go back to the emergency department are during the implementation of a "major emergency plan" or if there was a particular case that needed immediate attention as an "emergency".
The plan for emergencies was not put into action and once again he stated that he was unaware of Aoife's situation.
According to Dr. Gray, the primary emergency strategy called for multiple consultants, including himself, to come back to the hospital. Additionally, he mentioned that patients with non-critical conditions would have been relocated from the ED.
He stated that if this situation occurred, it would have been beneficial.
He expressed regret for not being informed about a 16-year-old kid who was admitted to the emergency ward in a severe condition of septic shock. This young patient had a category two status but couldn't be taken to the Resus ward as it was already overflowing with patients.
According to him, individuals referred to as "borders" and are considered no longer in need of emergency department attention are frequently left in the ED due to the lack of alternative placements.
According to Dr. Gray, in the year 2022, the HSE PMIU (performance management integration unit) was successful in putting an end to the practice of hospital staff moving trollies from the ED to the wards to relieve pressure on the ED. This practice had become a part of the hospital's internal culture.
According to him, the latest regulations were "nonsense" in his perspective and have not been effective in practice.
According to him, the employees had experienced difficulties in reinstating the former practice of relocating carts to hospital wards.
He mentioned that there were "two powers" functioning within the hospital that were "beyond my ability to regulate".
Dr Gray admitted that a plan for escalation was put in place following the tragic death of Aoife. Under this scheme, patients who had sepsis or were classified as category two would receive treatment within 30 minutes at most. However, Dr Gray agreed that these patients needed to be seen within a much shorter time frame of ten minutes.
The problem of low bed capacity and the negative impact of overcrowding on the emergency department meant that the escalation plan was not working as effectively as it could have been.
It was fortunate that most of the urgent cases occurred during the daytime rather than nighttime, "since we have more staff available to handle them," he remarked.
According to Dr. Gray, those who possess the most extensive understanding of the events that took place during Aoife's hospital admission are "the individuals who were present in person", which does not include him.
As per his viewpoint, the hospital needs to have a minimum of 300 beds along with two blocks of 96-bed that will be available soon.
According to him, if additional space is not made available, healthcare professionals will have no choice but to evaluate and treat patients in the hallways.
He concurred that UHL is always the most jam-packed hospital in the nation and that during weekends, only one emergency department consultant is available off-site.
"I am not in charge of setting the regulations, this standard is insufficient. In a perfect scenario, we would require a specialist present at all times on location."
According to Dr Gray, the fact that certain Category 2 patients had to wait as long as 19 hours to receive a medical evaluation was deemed "unacceptable."
"The situation was perilous for Aoife Johnston," he reiterated.
He stated that he did not participate in taking care of Aoife. He was solely requested to return to keep up with the overflow as stated, "Just to make it plain, the task of being an ED consultant on call does not include coming in when the space is packed."
When Mr Tansey pointed out that Dr Gray was the most experienced doctor available, and that his assistance was needed to support the overworked nurses, Dr Gray responded by saying that he wasn't capable of performing miracles like Superman.
If he had known about Aoife, he mentioned that he would have gone back to the emergency department. He highlighted that no one requested him to come back about any particular incident.
In the court, Carol Johnstone expressed her heartfelt tribute to Aoife, stating that she was a well-behaved child.
"I understand that most parents say this, but our daughter never caused us any trouble. She was a well-behaved child and, as my partner James would describe her, she was an awesome child," Carol Johnson stated, with tears forming in her eyes.
Her husband, who could be easily seen to be emotional and upset and had also displayed these emotions during his testimony in court, recounted how he had pleaded with staff members to assist his child during the inquest. He described his beloved daughter, Aoife, as being an amazing and awesome kid and she had a special place in his heart as his closest friend and precious baby girl.
Afterward, they both grinned and recollected their fond memories of Aoife: "We shared wonderful moments, Aoife accompanied us on vacations annually, despite her claims of being too trendy for it, but truthfully, she savored every moment spent with us. Aoife devoted significant time with us."
Their statement directed towards the Taoiseach and the Health Minister centers around the belief that the government's actions in 2009 to shut down three emergency departments operating around the clock in the area and direct them towards Limerick should be overturned.
When questioned about the reopening of the EDs in Ennis, Nenagh, and St. John's, they unequivocally stated that they should be reopened without a doubt.
It's very obvious that they require an additional emergency department, without a doubt.
Aoife has departed, hence offering apologies or implementing measures now will not result in her return. It will not alter the fact that she is no longer here.
Kate and Meagan, who happen to be Aoife's sisters, had a breakdown right outside the court while clutching framed pictures of their deceased sibling.
Kate Johnston's voice sounded choked up as she expressed that Aoife was "the most excellent individual."
According to Meagan Johnston, Aoife was the best sister she ever had and it pains her that she didn't have the chance to bid farewell to her. She declares that she will always remember Aoife forever.
Bernard Gloster, who is the chief executive of HSE, expressed his genuine sympathy to the Johnston family.
Mr. Johnston acknowledged that there is nothing that can fully compensate for the great tragedy that the Johnston family has endured.
He said that they will thoroughly assess the proposals made by the Coroner and also take into account the findings of the retired Chief Justice Frank Clarke, who is expected to finish his unbiased inquiry in the upcoming weeks.
