Consultant warns Aoife Johnston (16) inquest that UHL emergency department was ‘a death trap’

An emergency consultant who declined to attend University Hospital Limerick (UHL), despite a request from a nurse manager concerned about a spiralling overcrowding crisis, told the inquest into the death of Clare teen Aoife Johnston (16) that overcrowding had left the emergency department resembling “a death trap” that weekend.

Dr James Gray stressed that he was never directly consulted on or asked for advice about the teen’s condition – but said that Aoife was failed both by the emergency department and the healthcare system.

“Aoife Johnston had no chance. That is the tragedy of this situation. Had she been seen when she should have been then she would have had a much better fighting chance which she did not have, unfortunately.

“It was a death trap for Aoife Johnston (because of overcrowding). It (ED) was grossly overcrowded – it was unable to function and if anything happened, it happened very slowly,” he said.

“It was beyond an emergency – it was an abuse of human rights. I was physically unable to come every single time I was called about it being overcrowded. It was always overcrowded.

“You have good staff working in a very poor environment. Every conceivable space is full of patients. There was leadership but unfortunately leadership just couldn’t cope with the situation.”

Dr Gray said the only thing that could have coped with the situation in the UHL emergency department that weekend was triggering UHL’s major emergency plan.

In that situation of the emergency plan being triggered he said the emergency department would have been decompressed.

He acknowledged that UHL faced a chaotic situation that weekend.

The consultant said he would immediately have attended UHL had he known a 16-year-old girl was at the hospital in septic shock.

“I had been in for the day – I was on for 48 hours. I had been fielding calls throughout the day from three local injury units. I got a call at 10.28pm from the senior clinical nurse. She articulated to me that the department was extremely busy. I asked had she escalated the matter (to allow surge measures to ease pressure on the department).”

“I said: ‘Look, Katherine (Skelly) I have been in during the day – I have to be in in the morning. I just cannot come in now.”

The specific case of Aoife Johnston was not raised.

Dr Gray stressed to counsel for the Johnston family, Damien Tansey SC, that he had been on duty all day and had to be on duty from 8am the following day.

“I am not Superman. It is impossible – it is busy every day. It (UHL) is still the busiest hospital in the State today. The problem here is that you had one consultant on for the entire weekend – it is not good enough. I do not make the rules. There needs to be a lot more consultants to provide that 24 hour cover.

“Unfortunately there is going to be pinch points.”

But he stressed that it was “completely unacceptable” to see Category Two patients waiting for up to 19 hours for vital treatment.

“I wish – had I known there was a 16-year-old child who entered the emergency department in septic shock and who could not get into the [resuscitation] room – the system failed her.

“The emergency department failed her. If I had known there was a patient like that there I would have come in. The problem is that I was not asked to come in about a specific case.”

The inquest has already heard that consultants will attend the UHL emergency department for major emergency cases but not for volume matters.

Just one Senior House Officer Dr Leandri Caird was left dealing with over 170 patients on December 17 as a flood of patients attended the emergency department – but the two senior registrars spent most of their time in the resuscitation room dealing with just over 14 patients, most having suffered fractures due to a cold snap.

UHL emergency department nurses were so worried about the situation they pleaded with the registrars to leave the resuscitation room and focus on seriously ill patients in other parts of the emergency department.

“I was not consulted to give advice or to attend Ms Johnston directly,” Dr Gray said.

“UHL is a Model Four hospital – all the others feed into that.

“When I am on site I am the most senior person from a medical perspective.

“I attended at UHL on Saturday during the day and at UHL on Sunday during the day. I was called almost every hour after I left UHL because local injury units were dealing with cases.”

The consultant gave evidence as Limerick Coroner John McNamara is set to conclude the four day inquest in Kilmallock later today (Thursday).

The inquest has been attended every day by Aoife’s parents, James and Carol, and her sisters, Meagan and Kate, as well as extended family and friends.

At the request of the family, two framed photographs of Aoife are on the bench in front of the coroner.

The hearing was previously told by Consultant Microbiologist Dr Patrick Stapleton that Aoife would likely have survived her meningitis infection had she received antibiotics in time.

However, the teen did not receive the necessary antibiotics for 15 hours and 15 minutes after she attended UHL.

Aoife was brought to UHL by her parents, James and Carol, with a letter from a ShannonDoc GP advising she needed urgent treatment for suspected sepsis.

She did not see a triage nurse for almost an hour and a half after arriving at UHL at 5pm on December 17 2022.

Aoife was not seen by a doctor until 6am on December 18 – and did not receive antibiotics until after 7am.

She died from sepsis on December 19 after fatal brain swelling due to her infection.

Dr Stapleton said the Type B meningococcal infection which Aoife had contracted was readily treatable with targeted antibiotics.

“It is highly likely that the outcome would have been different and optimal,” he said.

Every two hour delay in administering the correct medications results in a twofold increase in meningitis and sepsis mortality risk.

Registrar Dr Muneeb Shahid, who was responsible for the emergency department section at UHL where Aoife was on December 17/18 2022, said he cannot recall a nurse manager urging him to leave the resuscitation unit where fracture patients were being treated to check on more seriously ill patients including Aoife in Zone A of the emergency department.

UHL legal counsel, Conor Halpin SC, insisted to the inquest that Aoife was always a Category Two or seriously ill patient at UHL – after Dr Shahid raised the possibility that Aoife had been re-triaged to a less serious Category Three patient despite her having sepsis.

The UHL executive-on-call that night, Fiona Steed broke down and sobbed as she told the inquest that she thinks of Aoife every day and every night and will never forget “her beautiful face”.

Medical witnesses stressed the circumstances of Aoife’s death had a profound impact on everyone associated with UHL.

Ms Steed admitted that understaffing and overcrowding undermined the ability of the hospital to care for its patients.

She said overcrowding over December 17/18 was “horrendous”.

Ms Steed, a former UHL general manager who is now with the Department of Health, wept as she was asked if the circumstances of Aoife’s death had moved her.

“I have been moved by Aoife’s death every night and every day since. I look at my daughters and realise how lucky I am to have them. I think of Aoife.”

“I will never forget Aoife or her beautiful face. These are not hollow condolences. It has completely altered my approach to life and my approach to my children.”

Members of the Johnston family became visibly upset during Ms Steed’s evidence.

Aoife’s sister, Meagan, left the inquest courtroom in tears as she said: “We go home without Aoife every day.”

She was comforted by her parents, James and Carol, and her sister, Kate.

Ms Steed said that the words “major emergency” and “warzone” were never used to her on the night of December 17 in terms of the chaotic conditions in the emergency department.

“Those words were not used to me on Saturday. They were used to me on Sunday.”

Ms Steed was asked by counsel for the Johnston family, Damien Tansey SC, what she did when she became aware that two consultants had declined to attend UHL emergency department despite a call from a nurse manager warning about the spiralling pressure on staff.

A paediatric consultant declined to attend but then arrived at UHL within 30 minutes and worked for over two hours to assist patients – with one nurse manager saying his work helped make a great difference.

Emergency Consultant Dr James Gray declined to attend.

“I called the (UHL) Clinical Director and said that Dr Gray did not come in. It is not a complaint – I escalated it.”

Ms Steed said she alerted him (Clinical Director) by text but did not receive a reply that night.

“I do not have the power to compel consultants to come in (to the hospital).”

She advised medical staff on duty that night to implement a surge policy, to reopen some units and to transfer patients on trolleys from the emergency department to wards.

However, this ward transfer was not done due to infection and geriatric care concerns.

“When I didn’t hear back…I wrongly and regrettably thought my advice had been followed. The emergency department should not hold all the risk as it did that night – absolutely it was. It should have been spread across the (hospital) group.”

Assistant Director of Nursing Patricia Donovan was the ADON on duty in UHL when Aoife was brought to UHL’s emergency department.

James and Carol Johnston warned they had to watch their daughter dying despite their desperate and repeated pleas for her to be helped.

Aoife had been placed in what they described as a storeroom in the emergency department – and as there were no trolleys available they created a make-shift bed for her from two chairs.

Despite being the most seriously ill patient in the emergency department, Aoife was not mentioned in the nursing handover report on December 18.

ADON Donovan said UHL that evening faced a shortfall of 21 nursing staff – 17 of which were known about in advance and four were unplanned.

Aoife arrived in UHL as Ireland went from a Status Red to a Status Yellow ice alert and the hospital faced a flood of patients injured in ice-related falls.

Concerns about overcrowding in the emergency department were brought to Ms Donovan’s notice by the Clinical Nurse Manager on duty, Katherine Skelly.

Ms Donovan said that senior managers were alerted and surge measures were organised amid growing concerns over patient treatment waiting times.

“I recommended that she (Katherine) contact the Emergency Consultant Dr Jim Gray and the Paediatric Consultant and advise them of the activity in the departments,” she said.

“In particular I wanted the consultants to be aware of the number of Category Two patients awaiting treatment. The Emergency Consultant would only attend for a major emergency and not for volume,” she explained.

Mr Tansey SC asked what her response was to this refusal?

“(I was) disappointed – not surprised but disappointed,” she said..

Ms Donovan wept as she addressed the Johnston family.

“As Katherine (Skelly) said it (Aoife’s death) has impacted hugely on all of us that worked there and still work in that department. I cannot know your pain. I am very sorry (for your loss),” she said.

Aoife arrived at UHL at 5.40pm on December 17 – but didn’t receive the critical antibiotics until around 7am on December 18, a delay with tragic consequences.

The inquest dealt with extensive evidence from medical personnel on duty over that 48 hour period.

It emerged that several nurses and nurse managers had desperately sought clinical support measures given the spiralling pressure on the emergency department over December 17/18 2022.

Mr Tansey said that three separate opportunities to intervene to save Aoife were missed.

One nurse said she had tried on three occasions to bring Aoife’s case to the attention of doctors over the course of the evening.

The numbers in the emergency department soared from 101 to 191 patients in just over 24 hours.

Category Two patients, which require treatment within 15 minutes, faced lengthy delays in treatment due to the overcrowding.

The longest wait for a Category Two patient that weekend was a shocking 19 hours.

A less ill Category Three Patient faced a wait time of up to 39 hours.

UHLG Clinical Director Dr Damien Ryan, who was not in the role when Aoife died, said the issue of overcrowding and patients spending excessive time on trolleys will be addressed when a new 96 bed unit opens at UHL and further investment in the hospital is completed.

“It is not satisfactory,” he said in terms of the conditions at UHL over December 17/18 2022.

He warned that overcrowding was “a massive problem” at some Irish hospitals.

Dr Ryan acknowledged that overcrowding was a particular problem in Limerick.

“It (UHL) is the hospital in the region that others feed into. One of the things we have put in place (after Aoife’s death) is an emergency department escalation plan. It has a number of triggers – the number of patients in the department, the number waiting to be seen, the number of Category Two patients.”

“It is fair to say that if the scenario pertained today, the emergency medical consultant on call would attend under the emergency escalation plan.”

The inquest is set to conclude today.

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