Medical misadventure verdict at Aoife Johnston inquest

A verdict of medical misadventure has been returned at the inquest into the death of Aoife Johnston.

Limerick Coroner John McNamara delivered his verdict after four days of evidence at Kilmallock Courthouse.

Ms Johnston, from Shannon in Co Clare, died from meningitis on 19 December 2022.

The 16-year-old had presented at the Emergency Department at University Hospital Limerick two days earlier, with suspected sepsis, but faced a lengthy wait for treatment.

Mr McNamara expressed his sincere condolences to the deceased's family and acknowledged the difficult week they had at the inquest, reliving the events of December 2022.

He said there were systemic failures, missed opportunities and communication breakdowns throughout Aoife Johnston's time in the ED at UHL.

Mr McNamara said he was concerned at the ongoing problems at the hospital.

The coroner has issued a number of recommendations along with his verdict.

These relate to the future management of suspected sepsis patients in the hospital, as well as covering the manner in which hospital managers can trigger an escalation of services in emergency situations, such as those experienced in the ED on the weekend of Ms Johnston's death.

In his concluding remarks to the inquest this afternoon, solicitor for the Johnston family Damien Tansey SC, said they wanted to ensure no other parents would have to experience what they had gone through.

Mr Tansey said Aoife Johnston was "a beautiful girl by any measure".

Watch: Parents say they thought Aoife Johnston was 'in best place'

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He said she had an illness that was eminently treatable and that it was not acceptable that a citizen of this country was treated in the manner she was.

He said this week's proceedings were part of a mission by the Johnston family "to vindicate and underpin Aoife's standing as a person".

In a statement, the Minister for Health said his thoughts were with Ms Johnston's parents after "an immensely difficult week".

Stephen Donnelly said: "I wish to offer my sincere condolences to Aoife's parents and sisters who tragically lost their daughter and sister in University Hospital Limerick.

"I met with Aoife’s parents in January and my thoughts are with them after what must have been an immensely difficult week.

"I would like to thank the coroner for all his work this week, but I am aware that nothing will ever make up for the enormous loss the Johnston family has experienced."

Mr Donnelly added that the coroner's recommendations will be "fully considered" as well as the work of retired Chief Justice Frank Clarke, who is due to conclude an independent investigation in the coming weeks.

The Chief Executive of the HSE has said he would like to express "heartfelt sympathy" to the family of Ms Johnston.

"I want to take this opportunity to restate for the record today our unequivocal apology to them, conscious that no words of mine will take away their pain," Bernard Gloster said in a statement.

He said he would study the inquest and take it into consideration alongside the outcome of Mr Clarke's independent review.

"I know we have considerable work to do to ensure that the people of the midwest, and the staff of University Hospital Limerick, have a service they can feel confident in and proud of, and we are working to that end," he said.

"The details of this inquest will be very much in our minds as we do so," Mr Gloster added.

Earlier, a consultant at University Hospital Limerick said the UHL Emergency Department was "like a death trap" on the weekend that Aoife Johnston presented at the facility.

The inquest has already heard testimony that Dr Gray was asked to attend at the ED on the night of 17 December 2022, given the immense pressure on staff, as a result of overcrowding there.

He told counsel for the Johnston family that he was not asked about a specific case by colleagues in the department.

Under cross-examination by Damien Tansey, he said he had been telephoned by Nurse Katherine Skelly at 10.28pm on the night in question.

She articulated that the department was extremely busy and asked if he could come in.

Dr Gray said he had an extremely busy workload and had to be back in the ED at 8am the following morning.

He had to work in the clinical decision unit on the Sunday morning and was the only person who could carry out that task.

"Had I known there was a 16-year-old child in septic shock, a Category 2 patient, who couldn't get into the resus room, the system failed her, the ED failed her, but if I had known there was a patient like that in the department, I would have come in. The problem is I wasn’t asked about a specific case," Dr Gray said.

He agreed with Mr Tansey that he was a "pivotal cog in the wheel of the hospital" and the need for his level of experience was extremely important.

Dr Gray outlined how he was working a 48 hour on-call shift on the weekend of 17/18 December 2022. He attended the ED on Saturday and Sunday, during the day.

In addition to his role at UHL, he was also charged with dealing with matters in relation to local injury units at other facilities in the hospital group, in Ennis and Nenagh.

Dr Gray said he had fielded calls almost every hour from staff at these locations, given the number of presentations they were experiencing.

Mr Tansey put it to him that the Johnston family were of the view that had a consultant attended the ED, they would have had the authority to redeploy staff to ensure better patient flows.

But Dr Gray told the inquest that it is impossible for a consultant who is on call for 48 hours to come in if it is busy "because, guess what, it’s always busy".

He said there was a very chaotic situation at the ED and told Mr Tansey "I’m not Superman".

Dr Gray compared the ED as being like an aeroplane with passengers on every seat, with others lying in the aisles. As a result, it could not function properly.

"You have good staff in a dysfunctional environment," he said.

"There was leadership, unfortunately the leadership was not able to manage the situation."

Dr Gray said the only way to have eased the pressure in the ED that weakened would have been to implement a major emergency plan. He said this was a function for the executive on call. This did not happen.

He went on to describe the care given to Aoife Johnston as being without dignity or privacy.

"It’s an abuse of human rights," he said.

Dr Gray told the inquest the emergency department at UHL is "consistently the worst in the country".

When asked by Mr Tansey if there were any cost neutral remedies that could be put in place immediately, he said the short answer was no.

The inquest has heard that part of the problem in the emergency department is that patients requiring admission to hospital cannot be moved from the facility due to pressure on bed spaces elsewhere.

Dr Gray said there had been a culture of moving some trolleys from the emergency department to the wards, but that stopped in 2022.

He said the idea that wards would function better if they had no trolleys was "rubbish, that's not the way it works in reality".

He said the reconfiguration of accident and emergency departments in the midwest in 2009 had resulted in a new emergency department in Limerick, but UHL was never given the number of extra beds it needed to function properly.

Dr Gray said the emergency department was still a "death trap" and that plans to add extra facilities at the hospital would not solve the problems there.

He said a new 96-bed block under construction was a step in the right direction.

But even another development, with a similar number of additional beds, due to be completed by 2028, would not be enough.

Dr Gray said that at least 300 additional beds were needed in UHL to resolve the overcrowding in the emergency department.