Systemic failures at University Hospital Limerick led to death of Aoife Johnston, says coroner

Verdict of medical misadventure recorded for 16-year-old who died of “treatable” illness

Meagan and Kate Johnston (holding photographs of their sister Aoife), their parents Carol and James Johnston, with Damien Tansey, solicitor for the Johnston Family, at Kilmallock Coroner's Court. Photograph: Brendan Gleeson

Aoife Johnston’s “treatable” illness should have been dealt with in a timely manner when she presented at University Hospital Limerick – and when she did receive the care she need, it was too late, a coroner has said.

As he recorded a verdict of medical misadventure into her death on Thursday, John McNamara, presiding at Limerick Coroner’s Court, said there were systemic failures, missed opportunities and communication breakdowns at University Hospital Limerick (UHL) during the period in which Ms Johnston (16) attended there prior to her death.

Ms Johnston, late of Shannon, Co Clare, died at UHL on December 19th, 2022, from purulent meningitis. She had presented at the hospital’s emergency department two days earlier, at about 5pm on December 17th, suffering from a suspected case of sepsis.

The inquest heard on Thursday of the “gargantuanly overcrowded” emergency department Ms Johnston arrived at, described by Dr James Gray, the emergency medicine consultant on call that weekend, as “a death trap”.

Aoife Johnston: "Had no chance," doctor told inquest.

“Aoife Johnston had no chance,” he told the inquest on Thursday.

Despite being triaged as a high-priority patient in need of care within 10 to 15 minutes, Ms Johnston waited for hours in the hospital’s emergency department, and did not receive “vital” antibiotics until after 7am on December 18th.

Summarising the evidence put before the inquest, Damien Tansey SC, solicitor for the Johnston family, noted that a number of medical witness stated that the department “couldn’t function”.

“It was a dangerous, dangerous environment, for this dangerously ill patient to find herself in,” Mr Tansey said. The situation in the emergency department was “intolerable” for both doctors and nurses present, he said.

He also noted previous evidence which stated that two registrars working in the emergency department spent extended periods of the night in question caring for up to 14 patients in the department’s resuscitation room, leaving scores of other patients, including Ms Johnston, to wait hours for care.

Dr Gray, who agreed that he was the most senior clinician working in the hospital’s emergency department while “on-site”, had declined a request to attend the hospital on the night of Ms Johnston’s admission. He noted that it was impossible to attend the hospital due to capacity difficulties at the emergency department, “because it was always overcrowded”.

“I was physically unable to come in,” he said. “I’m not Superman.”

He said he would have attended the emergency department on the evening that Ms Johnston presented at the hospital, had he known about her case.

He noted that when she did receive care from Dr Leandri Card – the senior house officer on duty in the emergency department over the weekend – around 6am on December 18th, “she got good care, but it was far too late”.

He said “the only thing that would have worked” in tackling the crisis unfolding at the hospital was enacting the hospital’s “major emergency” plan, but this did not happen. Activating the plan would have triggered a “cascade” effect, with consultants on call required to attend the hospital.

Mr Tansey, for the bereaved family, said the manner in which Ms Johnston was treated was “not suitable” for “one of the citizens of this country ... in one of our [medical] centres of excellence”.

He said the Johnston family were on a mission “to vindicate and underpin” Ms Johnston’s life and standing as a person. “She will always be a member of this family,” he said, gesturing to the Johnston family sitting behind him in the courtroom.

Mr Tansey said it was the Johnstons’ “fervent wish ... that there will never be a day like this for other families”, and that they hoped some good would come from “an unspeakable tragedy”.

The court heard on Thursday that significant overcrowding issues persist at UHL.

Despite the implementation of recommendations from the Hamilton report – an independent report carried out following Ms Johnston’s death – the hospital’s emergency department is still a “very dysfunctional environment” today, Dr Gray said. “It’s still a dangerous place, unfortunately.”

Persistent problems pertaining to overcrowding, Mr McNamara noted before closing the inquest, were not acceptable.

Fiachra Gallagher

Fiachra Gallagher

Fiachra Gallagher is an Irish Times journalist