Clare teen's death in Limerick hospital "death trap" ruled "medical misadventure"

An inquest into the death of Aoife Johnston, the 16-year-old who died from meningitis at University Hospital Limerick in December 2022, returned a verdict of medical misadventure on Thursday, April 25.

Johnston, from Shannon in Co Clare, died on December 19, 2022, after presenting at the Emergency Department of University Hospital Limerick two days previous with suspected sepsis.

In the hospital, she faced a lengthy wait for treatment despite displaying severe symptoms. The teenager ultimately waited more than 15 hours to receive antibiotics, which would likely have saved her, the inquest heard.

The inquest into Johnston's death took place over four days at Kilmallock Courthouse in Co Limerick and was attended by her parents’ siblings, relatives, and friends.

Dr. Jim Gray, who was the consultant on call at UHL the weekend of Johnston's death, told the court during the inquest that the ED was "like a death trap" on the weekend the teenager died. 

He said that he was asked to attend the emergency department on the night of December 17, the night Johnston's parents brought her to the hospital after being referred by a GP, due to the immense pressure on staff.

He said that he was not made aware of any specific cases and that he worked in the hospital's clinical decision unit throughout the day on Sunday, December 18. 

He told the court that the system "failed" Johnston. 

"Had I known there was a 16-year-old child in septic shock, a Category 2 patient, who couldn't get into the resus room, the system failed her, the ED failed her, but if I had known there was a patient like that in the department, I would have come in," Dr. Gray told the inquest, according to RTE News.

"The problem is I wasn’t asked about a specific case."

Dr. Gray said the ED at UHL is "consistently the worst in the country" and that Johnston received care without dignity or privacy. 

"It's an abuse of human rights," Dr. Gray told the inquest. 

Limerick Coroner John McNamara delivered the verdict of medical misadventure after hearing four days of evidence at Kilmallock Courthouse on Thursday.

McNamara said there were systemic failures, missed opportunities, and breakdowns in communications throughout Johnston's time in the ED, adding that he remains concerned by ongoing problems at the hospital. 

McNamara also issued a number of recommendations related to the future management of suspected sepsis patients at University Hospital Limerick. He also issued recommendations related to how the hospital can trigger an escalation of services during emergency situations such as Johnston's. 

"I never got to say goodbye"

Speaking outside Kilmallock Courthouse on Thursday, Aoife's older sister Meagan told reporters through tears: "I will never forget Aoife - she was just the best sister ever.

"It kills me all the time that I never got to say goodbye to her.

"When I got that call, Aoife was already gone. I'll never forget that drive into to the ICU.

"I immediately made my boyfriend drive me in there to see my sister.

"I never got to say goodbye to my little sister. I never go to say goodbye to her - she was gone.

"I never got to see my sister complete her Leaving Cert, I never got to see my sister do her graduation, I never got to see my sister moving onto the next chapter with her boyfriend, he's left heartbroken.

"When I knew Aoife was in hospital, I thought she was going to be okay. And then the next morning to get a call that she's in ICU, I didn't know what to do.

"That's my baby sister. And we never get to see her again.

"But I'm just so grateful. She was a beautiful girl inside and out. She's just an amazing person and I'll cherish the memories of her forever and forever.

"I'm just so sorry, Aoife, what happened to you. My mom and dad did everything they could for her."

Aoife's mother Carol told reporters on Thursday: "We welcome the verdict and apologies but it's not going to change anything.

"Aoife's gone and that's what we have to live with now."

She added: "We brought Aoife where we told her she would be looked after, but she wasn't. We told her she was in the best place. Get some rest. The doctors will be here soon. And the doctors never came."

When asked what she hopes Aoife's legacy will be, her mother said: "Aoife is remembered at the minute as a girl who died on a trolley, that's how Aoife's known at the minute.

"But I suppose, in time, when me and James can talk to someone properly, people will get to know the real Aoife, the lovely 16-year-old  girl, and our baby, and who we loved very, very much, and her sisters loved her very much.

"You'll get to know Aoife then, not the 16-year-old girl who died on a trolley."

"Sincere condolences" and "heartfelt sympathy"

Ireland's Minister for Health Stephen Donnelly has offered his condolences to the Johnston family. 

"I wish to offer my sincere condolences to Aoife's parents and sisters who tragically lost their daughter and sister in University Hospital Limerick," Donnelly said in a statement. 

"I met with Aoife’s parents in January and my thoughts are with them after what must have been an immensely difficult week.

"I would like to thank the coroner for all his work this week, but I am aware that nothing will ever make up for the enormous loss the Johnston family has experienced." 

Donnelly said he will ensure that McNamara's recommendations are "fully considered," adding that he will also consider the verdict of former Chief Justice Frank Clarke, who is due to conclude an independent investigation in the coming weeks. 

HSE Chief Executive Bernard Gloster also extended his "heartfelt sympathy" to the Johnston family on Thursday. 

"I want to take this opportunity to restate for the record today our unequivocal apology to them, conscious that no words of mine will take away their pain," Gloster said, adding that he will also take McNamara and Clarke's recommendations into account. 

"I know we have considerable work to do to ensure that the people of the midwest, and the staff of University Hospital Limerick, have a service they can feel confident in and proud of, and we are working to that end.

"The details of this inquest will be very much in our minds as we do so."