‘Systemic failures’ seen in Aoife’s care

Solicitor Damien Tansey, second from left, with the Johnston family outside Kilmallock Courthouse. Picture: Brendan Gleeson

During four days of harrowing evidence, an inquest heard how Aoife Johnston — a teenage girl on the cusp of adulthood — died while in the care of University Hospital Limerick (UHL).

Aoife’s family had to endure the pain of listening on as the final hours of her young life were detailed by hospital staff, in the hospital where they believed she was “safe”.

For the Clare teenager’s family, the inquest is there to provide answers.

However, they also wanted the coroner to know that what happened to Aoife can never happen again.

Questions are now being asked about why medical staff at UHL allowed 16-year-old Aoife to be left without vital antibiotics that could have saved her life from meningitis.

The horror of what happened to the youngest child of the Johnston family, who “fell between two stools” at a centre of excellence catering for 425,000 people in the Midwest region, has raised serious questions about the lack of care provided to her.

Coroner John McNamara said there could only be one verdict in the teenager’s death — medical misadventure — before he went on to describe “systemic failures and missed opportunities” in Aoife’s care.

Aoife Johnston, 16,  died after waiting 12 hours on chair to see a doctor at  University Hospital Limerick, in December 2022. Picture: David Raleigh

After the verdict, Aoife’s mother Carol Johnston said: “We told her she was in the best place, get some rest, the doctors will be here soon, and the doctors never came.

“Aoife had, in my words, a horrible death and she suffered all night. People need to know that.

“We welcome the verdict and the apologies, but it’s not going to change anything. Aoife is gone and that is what we have to live with now,” her mother added after the proceedings.

All medical advice states that if meningitis — an infection and inflammation of the fluid and membranes surrounding the brain and spinal cord — is suspected, immediate medical attention should be sought.

Having been referred to UHL by an on-call GP with suspected sepsis on December 17, 2022, Aoife waited for nearly 17 hours before receiving any antibiotics. During that time, she was left on a makeshift chair, “screaming in agony” while her terrified parents “roared” for help.

Even the 13 patients ahead of her told medical staff to see Aoife before them.

She arrived at UHL at 5.40pm and saw a triage nurse at 7.15pm, who described her as a category two patient — meaning she had to be seen within 10-15 minutes.

Time was of the essence. However, too much time passed and Aoife died on December 19.

The situation at the hospital that weekend was described by staff as a “death trap” and a “warzone” for patients. There were 191 patients in the emergency department and not enough beds or staff.

While some improvements have been made at UHL, consultant in medicine Dr James Gray — who was on call that weekend — said it still is the most overcrowded hospital in Ireland.

Dr Gray admitted that he declined to come in on the night of Aoife’s admission because he was on for the past 48 hours, and had meetings at 8am the next day — where decisions had to be made.

He shed some light on why UHL is under so much pressure and people don’t feel safe there. It became a category 4 hospital in 2009, and the status of St John’s hospital, Croom, Nenagh, and Ennis, were all reduced as a result.

The hospital is now serving a population of around 425,000, and three satellite injury units are also feeding into it.

A state-of-the-art emergency department was built at UHL in 2017, with 49 cubicles.

“But it didn’t get the bed cohort to be able deal with the reconfiguration of services that happened in the Midwest [region] in 2009,” Dr Gray said.

“There are not enough beds in the hospital for the size of the catchment.

They would need 300 [extra hospital] beds, at least, on top of what we have at the moment.

He said the system had “failed Aoife Johnston” and that she had “no chance”.

Katherine Skelly, a clinical nurse manager at the emergency department at UHL, said the hospital was overwhelmed due to an influx of acutely ill patients.

These patients presented with multiple fractures during a severe weather freeze alert, she added.

Dr Leandri Card was looking after 161 patients, but was persuaded to see Aoife “out of turn”.

She took Aoife’s vitals at 6am on December 18 and decided she had meningitis. She had prescribed her antibiotics, but they were not given until 7.15am.

Meagan Johnston speaking with reporters outside Kilmallock Courthouse, after the verdict of medical misadventure was delivered in Aoife's case. Picture: Brendan Gleeson

Aoife died from sepsis at 3.31pm on December 19, after fatal brain swelling due to her infection.

The Johnston family said they don’t want Aoife to be remembered as the teenager who died at UHL.

She was a beautiful girl who loved to make up and her clothes, she had a boyfriend, her sister Meagan said.

Aoife was in sixth year when she died. She had a close bond with her two older sisters, Kate and Meagan. She was the apple of her parents Carol and James Johnston’s eye.

“Aoife the coolest kid, she was my best friend, my baby girl,” her dad said.

In his closing submissions, the Johnson family’s solicitor, Damien Tansey, said it was the week before Christmas, and Aoife was on the cusp of the next phase of her life.

“Little did the Johnston family know that, within a matter of hours, their beautiful daughter would be dead. They find that very difficult to comprehend,” he added.

Mr Tansey referred to Van Morrison’s song ‘Days Like This’, and said the Johnston family hope there will never be a day like this for other families, if in some way some good comes from “an unspeakable tragedy”.