‘We watched our daughter die’ – parents of Aoife Johnston (16) tell inquest into her death in UHL

THE HEARTBROKEN parents of Aoife Johnston (16) fought back tears as they revealed how they begged doctors and nurses at University Hospital Limerick (UHL) to help their daughter as a Limerick Coroner’s Court inquest into her death began today.

The inquest heard that even other emergency department patients were pleading with staff to help the teen who was screaming in agony as her condition became critical.

The inquest heard that Aoife – despite having a GP referral letter which advised that she needed urgent treatment for suspected sepsis – was not given the proper treatment until almost 14 hours after she was brought to UHL.

The inquest opened before Limerick Coroner John McNamara with profuse apologies to the Johnston family from both the Health Service Executive and the University of Limerick Hospitals Group for the failings in care provided to Aoife in December 2022.

Both apologies acknowledged the catastrophic outcome of the failings involved and apologised to the Johnston family for what happened and the loss of Aoife which resulted.

Aoife’s parents, James and Carol, attended the Kimallock inquest alongside her sisters, Meagan and Kate.

The family requested that framed photographs of Aoife be placed on the table before the coroner to remind everyone of the needless death of the Clare teen.

Aoife’s parents delivered emotional testimony at the opening of the inquest on the horrific circumstances of their daughter’s death at UHL.

“We watched our daughter die,” Carol told the hushed courtroom.

“I would not wish it on anyone. God love her. We told her she was in the best place (UHL) but it turned out she was not.”

Aoife arrived at UHL with a referral letter from a ShannonDoc GP which alerted UHL that she had suspected sepsis.

The GP warned that the teen’s condition was urgent and that his referral letter should be given to UHL emergency department staff on their arrival.

Despite this, Aoife was not seen for triage for an hour and a half.

She was then placed in a wheelchair in what her parents described as a store room.

James and Carol had to try to create what they described as a make-shift bed from two chairs pushed together.

Aoife arrived at UHL at 5.40pm and the GP’s letter was handed in to staff.

However, Aoife was not seen for triage until 7:15pm – and was not seen by a doctor until 6am the following morning.

James said that he repeatedly begged staff on duty to help his daughter as her skin developed a blotchy-type rash and another mark developed near her eye.

She was violently getting sick and her vomit was green in colour.

“I was up and down to the nurses all night pleading with them to help my daughter,” James said.

“Aoife was screaming in agony with pain to her right leg and head. I heard people outside on the trolleys asking the nurses and doctors to help Aoife. At one point a man said: ‘Is Someone not going to go into that girl?’

“There was no trolley available so we tried to make a bed for Aoife with two chairs. Aoife’s skin became very blotchy. She also had a mark on her left eye which looked like a birthmark on the corner of her eye.”

“I brought this to the nurse’s attention. Aoife was violently vomiting and it was pure green liquid.”

“I continually begged for help. The response was a brown cup for Aoife to vomit into and on one occasion a rebuke: ‘I am well aware she is sick – but I have 70 other patients to look after’.”

James admitted he got angry at one point as he pleaded with staff to help his daughter who was crying in pain.

Carol said that at one point, after begging for hours for help for Aoife, they were told she would be treated as if she had meningitis.

But her parents were then asked to help medical staff by holding her down for an intravenous treatment as Aoife’s limbs were by now involuntarily moving.

Carole said some staff at UHL were “very mean” to Aoife because she could not stand up by herself for a test.

“At 6am my daughter was finally reviewed by a doctor. She was in agony with pain in her head, her right leg, she was vomiting and she had blotchiness on her skin.”

“The doctor told us that she would treat Aoife as if she had meningitis. After the doctor left, Aoife started to deteriorate even more. James went to the nurses station for help.”

“Aoife was taken to resuscitation. By this point, Aoife’s limbs were moving involuntarily. I was asked to hold down my daughter’s arms so they could administer treatment.”

“We were subsequently advised that Aoife would be put into an induced coma as there was a swelling on her brain and that the coma would allow her body to relax.”

“Aoife was moved to ICU. Following a number of scans we were advised that there was nothing that could be done to save Aoife.”

Counsel for the Johnston family, Damien Tansey SC, said that by the time Aoife received the appropriate treatment it was too late.

“At that point everything possible was done to save Aoife but it was too late,” he said.

Aoife, who was from Shannon in Co Clare, died at University Hospital Limerick (UHL) on December 19, 2022, after contracting bacterial meningitis and then sepsis.

Limerick Coroner John McNamara ordered an inquest into her death and it is expected to take four days at hearing this week. Mr McNamara is expected to hear extensive evidence on the circumstances at UHL’s emergency department as Aoife Johnston arrived for treatment.

It is expected that the number of patients in UHL’s emergency department at the time Ms Johnston was brought to the hospital will feature heavily in the inquest this week. Witnesses are expected to also include the nurses and doctors on duty in the emergency department.

Witnesses are expected to include the consultants on call on the weekend of Aoife’s attendance, including one emergency medical consultant who declined a request to attend the emergency department that night.

Mr Tansey, for the Johnston family, said it was “strategically convenient” that a key witness, the senior nurse on duty in UHL’s emergency department on December 17/18, would not be present before the inquest.

The nurse is currently in Australia though a sworn deposition from the nurse will be delivered to the inquest.

Mr Tansey queried why the nurse would not be available for evidence by Zoom link from Australia when a doctor is scheduled to offer evidence to the inquest via Zoom from India.

Mr McNamara stressed that as the nurse is out of the jurisdiction, he cannot make an order to compel her to attend.

UL Hospitals Group last month released a preliminary systems analysis report, which was ordered immediately after Ms Johnston’s death.

It found that a 12-hour delay had occurred in caring for the teen’s developing sepsis.

The study was conducted by two senior doctors who were not associated with UHL.

In one finding, it said that overcrowding was now effectively endemic at UHL’s emergency department.

They also found there was only one emergency department consultant on call over the weekend that Ms Johnston was brought for treatment. The report also stated that there were not enough nurses and medical staff on roster to cater for the large number of patients seeking treatment.

This, the study found, resulted in “low experience levels of low situational awareness” of matters in the emergency department.

It acknowledged that, on the weekend that Ms Johnston sought treatment, UHL was struggling to cope with unprecedented demand.

Such was the pressure on the emergency department over that period that UHL cancelled all non-urgent elective procedures.

An independent investigation into the precise circumstances in which the Clare teen died has been ordered by the Government and will be directed by former Chief Justice Frank Clarke.

The Johnston family, in a statement through their counsel Damien Tansey SC, said they want answers over what happened.

“The family are looking forward to the inquest when an opportunity will be afforded them, through their lawyers, to seek explanations as to why what happened in Limerick happened.”

Term of reference for the Clarke inquiry were published last January

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