Aoife Johnston inquest returns verdict of medical misadventure

Up to date: 8.44pm

The mother and father of Aoife Johnston , who died in a “dying entice” Emergency Division (ED) at College Hospital Limerick, following “systemic failures” in her care, mentioned their daughter died a “horrible dying”.

Carol and James Johnston mentioned they wished their daughter to not be remembered “because the lady who died on a hospital trolley”, however as “a contented, easy-going, happy-go-lucky lady, who went to high school and did summer time jobs”.

“Our pretty 16-year-old lady and our child was beloved very a lot by us and her sisters,” they mentioned.

Following 4 days of proof at Aoife’s inquest, Limerick Coroner John McNamara returned a verdict of medical misadventure in her dying from meningitis after she contracted sepsis.

Mr McNamara mentioned it was “the one verdict” open to him after it had been proposed by Damien Tansey, senior counsel and solicitor for the Johnstone household, and never opposed by barristers representing the HSE, UL Hospitals Group and administration on the hospital.

“There have been systemic failures and issued alternatives in Aoife’s care,” the coroner mentioned.

“There have been breakdowns in communication, clearly, all through her care,” he added.

The coroner mentioned he was personally “involved in regards to the overcrowding, as a local of Limerick”, however accepted adjustments had been being made.

Aoife was dropped at UHL by her mother and father on Saturday, December seventeenth, 2022, after a GP instructed them he suspected she was deteriorating with sepsis.

The inquest heard hospitals are required to deal with sepsis sufferers inside 10 to fifteen minutes. Nevertheless, UHL didn’t triage Aoife for over an hour.

Regardless of being categorised as a sepsis affected person, Aoife waited 12 extra hours for a physician to look at her.

Regardless of vomiting inexperienced liquid, struggling excruciating ache in her leg, and being light-headed and weak, Aoife waited greater than 15 hours in complete to obtain antibiotics, which might possible have saved her, the inquest heard.

Stream of sufferers

Aoife was put in what her mother and father described as a retailer room within the ED, as there was nowhere else for her to go because of the stream of sufferers.

Her father  wept as he instructed the inquest that he begged workers to assist his daughter.

Different sufferers had been advocating for Aoife, however she was not seen in time, the inquest was instructed.

The antibiotics she wanted had been available, however as a result of UHL was so short-staffed and overcrowded with sufferers, workers had been delayed in giving them to her.

Her mind swelled and she or he by no means recovered, the inquest heard.

When she bought the antibiotics it was “too late” and she or he was “past restoration”, Mr Tansey mentioned.

Dr Jim Grey, who was the one ED advisor on-call that weekend however who was not required to be on website, instructed the inquest that not solely was the ED a “dying entice” on the night time in query, “it’s nonetheless a dying entice” 5 years after Aoife’s dying.

Dr Grey mentioned he was involved for sufferers attending the ED to at the present time, and that regardless of enhancements at UHL: “It’s nonetheless a harmful place.”

He mentioned there weren’t sufficient beds to fulfill affected person demand and there was nonetheless just one ED advisor on-call and off-site at weekends.

He mentioned it was fortunate that a lot of the emergency circumstances that current on the hospital are in the course of the daytime and never at nighttime when the hospital doesn’t have the identical variety of workers.

He mentioned workers numbers have elevated since Aoife’s dying, and measures aimed toward easing overcrowding are being carried out, however these adjustments weren’t being made rapidly sufficient.

“Aoife Johnston had no likelihood,” he instructed the coroner. “The system failed her, the ED failed her. ”

He added: “It was a dysfunctional setting, it was past an emergency — it was an abusive of human rights.”

Underneath cross-examination by Mr Tansey, Dr Grey admitted he had declined a request from a nurse supervisor to return in on the night time Aoife attended the ED.

Overcrowded

Dr Grey instructed the inquest that consultants who’re on-call however off-site at weekends, as he was then, and wouldn’t usually return to the ED for overcrowding “as a result of it’s all the time overcrowded”.

He reiterated that he acquired one telephone name on the night time in regards to the unfolding overcrowding disaster however he was by no means instructed about Aoife.

Indicating he was exhausted when he took the decision, Dr Grey mentioned: “I used to be bodily unable to return each single time I used to be referred to as about it being overcrowded, it was all the time overcrowded.”

“You’ve gotten good workers working in a really poor setting – there was management, however sadly, management simply could not address the scenario.”

There was just one nurse and one physician accountable for nearly 200 sufferers who had been squeezed collectively alongside the corridors of the ED’s Zone A.

Dr Grey mentioned he had been on the hospital earlier on the day and left at 3pm, because it occurred two hours earlier than Aoife arrived.

He mentioned he was on-call and providing phone help to workers in addition to fielding calls “each hour” from three native harm clinics throughout Limerick, Clare and north Tipperary.

Mr Tansey mentioned the 2 most senior docs who had been on website on the night time, each registrars, had been treating a wave of fracture sufferers within the Resus room, off the ED, and it too was swamped with sufferers.

Nevertheless, they allegedly declined to look at Aoife regardless of a nurse making three makes an attempt to get them to see her.

Each Dr Mohammed Hassan and Dr Muneeb Shadid instructed the inquest they didn’t recall being requested to see Aoife.

Nurse Ciara McCarthy, who tried to get Aoife assist, mentioned she was instructed to proceed giving fluids and paracetamol to Aoife, however as Mr Tansey defined, she “might as effectively have been giving her smarties for all the nice it did”.

Mr Tansey mentioned one registrar had mentioned the fluids had been “as essential if no more essential” than the antibiotics Aoife had desperately required – which Mr Tansey described as “so absurd it needs to be disregarded”.

Regardless of acknowledging a rise in non-consultant hospital docs at UHL from 25 to 47, Dr Grey warned UHL “remains to be a harmful place”.

‘State-of-the-art’

The advisor instructed the inquest the current ED was “cutting-edge” when it was opened in 2017. Nevertheless, in his opinion, it was not match for function.

Dr Grey mentioned 24-hour EDs had been closed in north Tipperary, Clare and St John’s Hospital in Limerick in 2009, and reconfigured to UHL. Nevertheless, he mentioned UHL “didn’t get the mattress cohort to cope with reconfiguration”.

He mentioned the Mid-West was the one area with no Mannequin 3 hospital which would come with a 24-hour ED service to go with UHL’s mannequin 4 standing, and the one 24-hour ED service for a 425,000 inhabitants.

He added two 96-bed blocks approaching stream was “a step in the suitable route, nevertheless it’s not sufficient”.

When requested once more about his resolution to not come to the Ed on the night time, he reiterated he was not conscious Aoife was there: “Let me be very clear, I used to be by no means consulted to present recommendation to or attend the ED in respect of Ms Johnston.”

Dr Grey mentioned it was now clear there have been “gargantuan” ranges of overcrowding within the ED on the night time.

He mentioned the dearth of beds, lack of workers and surge of sufferers on the night time had positioned “hazard on high of hazard” within the ED.

There have been sufferers on trolleys taking on each accessible area within the Division, blocking doorways, bogs and corridors.

He described as “exemplary” the efforts of a junior physician who was making an attempt to handle 191 sufferers, together with Aoife.

Dr Grey mentioned he instructed the nurse, who requested him to return to the ED, that he had been working on the division earlier that day, and he was due again on the hospital the next Sunday morning.

“An additional individual, like a advisor, would not have maybe made the distinction chances are you’ll suppose it could have made,” Dr Grey instructed Mr Tansey.

He mentioned the one events  he could be compelled to return to the ED had been when a “main emergency plan was activated”, or if there was a particular “emergency” case he needed to cope with.

The emergency plan was not activated, and he once more mentioned he was not instructed about Aoife.

Dr Grey mentioned the most important emergency plan would have seen not simply him, however different consultants returning to the hospital, and he mentioned non-urgent sufferers would have been moved out of the ED.

He mentioned if this had occurred “it could have helped”.

“I want I had identified there was a 16-year-old youngster who had entered the Emergency Division in septic shock,” he mentioned.

ED care

He mentioned that sufferers who’re thought to be not requiring ED care, often called “borders”, are routinely left within the ED as there’s nowhere else to place them.

Dr Grey claimed an HSE Efficiency Administration Integration Unit (PMIU) in 2022 had successfully “stopped” an inside tradition on the hospital of workers shifting trolleys from the ED up onto wards with a purpose to ease strain within the ED.

He mentioned, in his opinion, the brand new tips had been “garbage” and so they weren’t working in actuality.

He mentioned workers had “struggled” to “reactivate” the earlier tradition of shifting trolleys to wards, including these “two forces” working on the hospital had been “outdoors off my management”.

Dr Grey acknowledged that an “escalation plan” was launched after Aoife’s dying which had meant that sepsis and different “class two” sufferers had been being seen inside a most of half-hour, however he agreed these sufferers needs to be seen inside “10 minutes”.

Mattress capability points and drains on the ED attributable to overcrowding, meant the escalation plan was not working at its “optimum”.

It was luck that almost all of emergencies on the hospital occurred in the course of the day time and never night time time “as a result of now we have extra of a workforce to cope with them” then, he mentioned.

Dr Grey mentioned the individuals who had the best data into what occurred on the night time Aoife introduced on the hospital had been “the individuals on website, on the bottom”, and he was not one in all these.

In his opinion, the hospital required “at the very least 300 beds” along with the 2 96-bed blocks approaching stream.

He mentioned that except extra capability was supplied, nurses and docs must “proceed assessing and seeing sufferers in corridors”.

He agreed UHL is “persistently” essentially the most overcrowded within the nation and that just one ED advisor stays on-call and off-site on weekends.

“I do not make the foundations, it isn’t adequate. In a great world, we’d have a advisor on website 24/7.”

Dr Grey mentioned it was “unacceptable” that some Class 2 sufferers on the night time had waited as much as 19 hours to be examined by a physician.

“It was a dying entice for Aoife Johnston,” he repeated.

He mentioned he was not concerned in Aoife’s care, and that he was solely requested to return to offer cowl for overcrowding: “Lets be clear, the function of an ED advisor on name is to not are available when it’s overcrowded.”

When Mr Tansey put it to him that that he was essentially the most senior medic on name, and that his “management” was required to assist the overwhelmed nurses, Dr Grey retorted: “I’m not Superman.”

He mentioned he would have returned to the ED had he been instructed about Aoife: “I’d have gone again in, I wasn’t requested to return in a couple of particular case”.

Persevering with her touching tribute to Aoife outdoors the courtroom, Carol Johnstone mentioned Aoife was all the time child.

“I do know each father or mother says it, however she was no problem to me and her dad, she was child, and as James would say, she was a cool child,” Carol Johnson mentioned, welling up.

Her visibly damaged husband, combating again tears, simply as he had when giving proof to the inquest, when he instructed how he “begged” workers to assist his youngster, instructed reporters: “Aoife the good child, she was my finest pal, my child lady.”

They then each smiled and remembered Aoife on happier events: “We had good occasions, Aoife got here on holidays with us yearly, though she would say she was not coming with us as a result of she was too cool however she beloved each minutes of it, aoife spent so much fo time with us.”

Their message particularly to  the Taoiseach and the Minister for Well being, is {that a} authorities coverage resolution in 2009 to shut three 24-hour emergency departments within the area and funnel them to Limerick needs to be reversed.

When requested if the EDs in Ennis and Nenagh and St. John’s shoud be reopened, they replied: “Sure, 100 per cent, undoubtedly.”

“It’s clear as day, they want one other emergency division, undoubtedly.”

“We will’t make that occur however from our expertise denfitely, it shouldn’t occur to a different youngster.”

“Aoife is gone now so the entire apologies and something they put in place now is not going to (deliver deliver her again), it’s not going to alter that.”

Aoife’s sister Kate and Meagan broke down outdoors the courtroom, holding framed photos of their useless sibling.

Kate Johnston mentioned Aoife was “the most effective individual”, her voice choking up.

Meagan Johnston mentioned: “I’ll by no means ever neglect Aoife, she was essentially the most wonderful sister ever, and it kills me that I by no means bought to say goodbye.”

HSE chief govt Bernard Gloster provided his “honest condolences” to the Johnston household.

“I’m conscious that nothing will ever make up for the large loss the Johnston household has skilled,” Mr Johnston mentioned.

“The Coroner’s suggestions can be absolutely thought-about, together with the work of retired Chief Justice Frank Clarke who is because of conclude his unbiased investigation within the coming weeks,” he added.