Doctor weeps as she tells Aoife Johnston inquest UHL was 'not a safe environment'

The South African native, who was working as a Senior House Officer (SHO) in UHL’s Emergency Department said “every inch of the floor space” was taken up by patients on trollies when Aoife presented on December 17, 2022.

“It was like a war zone. It was an impossible situation,” she said.

Dr Card told the inquest, which is being held at Limerick Coroner’s Court in Kilmallock, that due to overcrowding and pressure on staff, she and other doctors routinely prescribed medication for ED patients without first seeing or examining them. “It happens on every shift, every day,” she said.

Dr Card agreed with Damien Tansey, senior counsel and solicitor representing the Johnston family, that this was “not best practice”. Dr Card said it was the norm and the only way patients would get medication as quickly as possible, because doctors were too busy dealing with patients.

“It’s not a safe environment, you do what you have to do, it’s not best practice.” When asked by Mr Tansey if this practice would give rise to “adverse outcomes” for patients, Dr Card replied: “Definitely”.

She said that despite prescribing antibiotics for Aoife at 6.40am on December 18 to treat suspected meningitis, Aoife did not receive this medication for an hour and 15 minutes. 

Dr Card said the medicine, which it was heard would have potentially saved her life, “wasn’t given as immediate as it should have”.

The witness said she did not have access to where medicines were kept. Prescribed drugs were normally administered by nurses, but Dr Card indicated she was not blaming anyone for the delay: “It is common that it doesn't happen as immediately as it should, as the nurses are overwhelmed.” 

She agreed she was still “haunted and troubled” by Aoife’s death. She said doctors routinely “don’t have enough time” to read patient medical charts before prescribing medicines to them, instead they have brief exchanges with nurses who advise them of the patient’s symptoms.

Dr Card also agreed she was “by herself” as the only SHO on the ED floor on the night Aoife was brought in by her parents, and she was trying to “manage 191 patients”.

Category 2 patients

She said a severe weather episode had “exacerbated” overcrowding in the ED and that “Category Two patients”, including Aoife, who are regarded as seriously ill patients, were “deteriorating” due to lengthy waiting times to see a doctor.

The inquest heard that staff were not aware of any plans at UHL to implement measures to mitigate patient flow despite the hospital having prior notice of the weather alert.

Dr Card said the recommended time for a CAT 2 patient, which included Aoife, to see a doctor is between 10 and 15 minutes. However, Aoife lay for 12 hours across two chairs before being seen by Dr Card. There were no trollies for her to rest on and her parents said she was in “agony” as they called for “help” but they said “there was no help”.

Wiping away tears, Dr Card described as “intolerable” the situation in the Limerick ED. She said other CAT 2 patients were waiting longer than Aoife — some were waiting an average of 19 hours to see a doctor, and Category 3 patients were waiting 39 hours.

Aoife presented at UHL at 5.40pm on December 17, 2022. The hospital’s protocols for sepsis, which require sepsis-queried patients to be seen urgently, were not followed. Aoife was not triaged until 7.15pm that night, and she did not receive antibiotics until it was too late. She died at UHL on December 19.

Dr Card said she examined Aoife at 6am on December 18, 12 hours after Aoife had presented with a doctor’s referral letter querying sepsis, a life-threatening condition requiring urgent treatment.

Dr Card wept and took several deep intakes of breath to try to compose herself while giving evidence. She agreed she had been severely emotionally impacted by Aoife’s death and that the teenager’s death had led to her quitting the HSE.

Dr Card said the ED and adjoining Resus (resuscitation room) were “full up” of trolleys that were blocking doorways. She said: “There was no space, in or out.” She agreed there was not enough staff and too many patents which had created a perfect storm in the ED.

The doctor said Aoife’s death was “instrumental” in her decision to quit the HSE to work in a private health clinic, and she said she has not worked in an emergency department since.

Dr Card said she had scanned Aoife’s patient file prior to seeing her first at 6am on December 17, but she said she had not seen the GP's referral letter at this stage, in which the GP indicated he suspected Aoife was suffering from sepsis.

On Monday, former UHL clinical nurse manager, Katherine Skelly, said the ED was like a” war zone” and “in crisis” like she had never seen.

Ms Skelly, who was also deeply traumatised by Aoife’s death and retired from her post, said she had made several calls to more senior staff including UHL ED consultant, Dr Jim Gray, to come to the ED to assist her. However, she said “he declined” and told her he had been in already and would be in again the following morning. Dr Gray is expected to give evidence before the inquest on Thursday.

Aoife eventually underwent a CT scan on her brain after she became unresponsive, and her brain had swelled. Doctors put her into an induced coma to ease the swelling but she did not survive.

UHL triage nurse Ariane DeGuzman, told the inquest on Monday that after reading Aoife’s GP referral letter and examining her when she first arrived at UHL she went to Resus and asked a registrar there to accept Aoife but he refused. The Resus room was also overcrowded with patients.

The inquest continues this afternoon and is scheduled to run until Thursday.