Aoife Johnston inquest reaches verdict of medical misadventure

Her inquest took place over four days at Kilmallock Courthouse in Co Limerick attended by her parents’ siblings, relatives, and friends.

Coroner John McNamara returned a verdict of medical misadventure and said there were “systemic failures, missed opportunities, breakdown in communication, clearly the bottom line is Aoife should have been seen and treated that is without doubt”.

The teenager had presented at UHL on December 17, 2022, at 5pm, after being referred to the emergency department by her GP with suspected sepsis.

The child had been suffering from headaches, pain and vomiting.

In his submissions to the inquest, Damien Tansey SC, for the Johnston family, said UHL emergency medicine consultant Dr James Gray "described the casualty department in Limerick that weekend as a death trap".

“He said it is still a death trap. This is a category four hospital that is the principal provider of medical care for 425,000 people — it was dangerous upon dangerous. And that is troubling”.

He said the only verdict open to the Coroner John McNamara was medical misadventure, which he returned.

“You have it within your power to make recommendations,” he said in his submissions. He said Ms Johnston "was a Leaving Cert girl". 

"She obviously had great interest in style. She was beautiful. She loved her make-up. She loved her clothes.

“She had an illness that is eminently treatable. We live in the developing world. This is not a third-world country but on the basis of the way she was treated that night it would appear to be one.

“It is not appropriate that one of our citizens of this country was treated in that manner.” 

He said that the Johnston family “in a sense are on a mission, to vindicate and underpin Aoife’s standing and status as a person but also as a member of this family” and he hoped “lessons were learned”.

It is the wish of this family that no other family will ever experience what they went through, Mr Tansey said.

He said the medical misadventure was the only one open to the coroner and asked him to make recommendations.

Conor Halpin SC for UHL said they were not opposed to the verdict of medical misadventure, while Ciara Daly BL for Fiona Steed said she was not opposing the verdict.

'The emergency department failed her'

On Thursday morning, Dr Gray told an inquest into the death of Aoife Johnston that the “system failed her, and the emergency department failed her” and that Aoife Johnston had “no chance” because she was caught in a “death trap”.

Dr Gray, who was the consultant on call at the time of her death, said he was not made aware of the 16-year-old’s case. Aoife Johnston from Clare passed away after suffering with meningitis-related sepsis on December 19, 2022, at the hospital after waiting more than 16 hours to receive antibiotics.

Also on Thursday morning, Dr Terezia Laszlo Consultant Pathologist told the inquest that the cause of death was Purulent meningitis.

Her inquest is now in its fourth day at Kilmallock courthouse in Limerick before Coroner John McNamara. Several medical staff have given evidence since Monday — many of them have described the emergency department that night as a “war zone”.

Nurse Patricia Donovan told the inquest on Wednesday that two consultants were contacted to come in to help with the 191 patients in the overcrowded unit, however one declined and the other, Dr Fasih Khan, came in for two hours.

On Thursday morning, Dr James Gray gave evidence that he was the emergency consultant on call from 17 to 19 December, 2022, when Aoife Johnston was referred by her GP to the hospital with suspected sepsis. He described the emergency department that night as “dysfunctional and chaotic”.

“You have good staff working in a very poor environment,” he said. 

A dysfunctional environment, chaotic scenes of overcrowding, patients back-to-back on trollies, double lines in corridors. 

"It would be like an airplane that is full, passengers on seats, and the aisles are full of patients and every conceivable space is full of patients. You can imagine how that plane would function, it wouldn’t,” he said.

He told the inquest there was “leadership” that night but “unfortunately the leadership wasn’t able to manage the situation”. “The only thing that would have worked that night was to activate the major emergency plan. That’s a call that is made by the executive on call,” he said.

When asked by Damien Tansey SC for the Johnston family if that was the executive on-call’s responsibility, Dr Gray replied: “In conjunction with the people on the ground.”

Mr Tansey put it to him that Dr Gray was also “on call”. "I am not part of the executive team” he replied. “I was available to come in on a case-by-case basis, I was available if the major emergency plan was activated and I was available to give advice on the telephone if required, which I did all day.

“Then at 10:30pm I was asked to come in (over the phone) having done a day and I needed to be in in the morning by 8 o’clock, I am not superman,” he said.

Mr Tansey said: “I am not suggesting you are but if you are asked to come in and you are on call, you should be in”. Dr Gray described the situation as “impossible” and that he had been on for 48 hours.

“Guess what, it’s always busy,” he said. “It has been busy ever since. The hospital is the most overcrowded hospital in this state, today”.

Mr Tansey put it to him during his cross-examination that “children were in the arms of their parents” requiring attention and another pediatric consultant came in.

“I was not made aware of the case (of Aoife Johnston),” said Dr Gray. “I had a schedule at 8 the following morning which I couldn’t get out of, there was nobody else to do it.

“I had to make decisions in the early morning. Had I not been there those decisions would not have been made.

“The problem here is there is one consultant on for the entire weekend, I don’t make the rules it’s just the way it was. It is not good enough. In an ideal world a consultant would be there 24/7.”

He said changes could only happen in the hospital with more consultants and more people to provide care and that contractual changes would have to be made.

Mr Tansey said Aoife Johnston was lying on a makeshift bed put together by her parents and that she was a category two patient and should have been seen between 10 and 15 minutes after her admission.

Dr Gray said: “Ten minutes” and that the situation for Aoife was “unacceptable”. The environment, he said, was a “death trap for Aoife Johnston”.

Dr Gray continued: “The department was unable to function. “What needed to happen was a major emergency plan. It would mean that all of the on-call staff would come in.

There were between 40 and 55 patients who no longer require emergency care. On top of 150 patients that were emergency patients. They had no chance; Aoife Johnston had no chance.

Mr Tansey said the teenager’s condition was treatable and referred to the pathogens that existed in her system which were all amenable to the full spectrum of antibiotics — the inquest was told this on Wednesday.

He described again that she was on two chairs put together by her parents and was crying out in pain.

Dr Gray said she had “no dignity, no privacy, very poor” and he said it was “beyond an emergency, it was an abuse of human rights”.

“Had she been triaged quickly,” he said, “And seen and the sepsis bundle commenced within the hour, as per the protocols, then she would have had a better fighting chance, but she didn’t.”

Mr Tansey said while Dr Gray had agreed with his descriptions of the hospital that night, he should have come in. “You had it in your remit” to escalate the situation to the executive committed. Dr Gray said it was not in his remit.

He continued: “I was not aware of any individual case brought to my attention.” He said that he was at work on Friday, December 17 until 3pm and that the emergency department was “grossly overcrowded and grossly dangerous”.

He said he was in communication with the staff on the ground but did not talk to the executive council.

The inquest also heard there were 67 category two patients across the two zones in the hospital casualty department, the numbers Dr Gray said were “off the scale” and that “the department could not function”.

“Had I known there was a 16-year-old child who entered the emergency department in septic shock, a category two patient who couldn’t get into the resus room, I would have come in,” he said.

“The system failed her, the ED failed her” and he said that he “was not asked to come in about a specific case”. He also paid tribute to Aoife as a “beautiful girl” and gave his condolences to her family.

Closing arguments are due to be made on Thursday afternoon as the case comes to a conclusion.