DYING FROM A sepsis infection and vomiting while on a makeshift trolley that her parents made out of two chairs in the overcrowded Emergency Department at University Hospital Limerick, Aoife Johnston had waited over 15 hours for life-saving antibiotics that didn’t come until it was too late, her inquest heard today.
The inquest into 16-year old Aoife’s death at UHL in 2022, also heard from Fiona Steed, who was the hospital’s general manager and “executive on call” on the night Aoife presented at the hospital, who said advice she had given to staff on the night to try to alleviate the overcrowding was not followed through.
Steed, who left UHL to work as a policy advisor at the Department of Health, broke down in the witness box and told how at the time, despite having a managerial post at the hospital, she did “not have powers” to compel staff to do what she asked.
Steed wept and apologised a number of times to Aoife’s family for the circumstances of her death. Aoife died after the hospital’s protocols on seeing sepsis patients quickly were not followed.
As Aoife lay dying from a sepsis infection on a makeshift trolley that her parents Carol and James had made for her, as there were no trollies available in the ED, there had been a breakdown in communications between staff, there were deficits in nursing staff, there was a lack of ED doctors, consultants had refused to attend the ED when called upon by desperate nurses, the hearing heard.
Aoife died after she had waited 12 hours, while “vomiting” and “in agony” for a doctor to examine her. The hospital’s protocols on sepsis patients being seen by a doctor within 15 minutes were not followed, and antibiotics, which the inquest heard would have saved Aoife, and which were readily available, were not given to her until it was too late.
Damien Tansey, senior counsel and solicitor for the Johnston family, said Aoife was not given the life saving medicine until “15 hours and 15 minutes” after she first presented at the hospital. Aoife’s brain had swelled as she waited for help and she eventually died in ICU having contracted suspected meningitis.
Nurses told the inquest they were working under “unprecedented” “chaotic” and “war-zone” conditions as almost 200 patients swamped the ED and its adjoining corridors, the inquest heard.
Earlier the inquest heard apologies for “failings” in Aoife’s care that led to her death, read out on behalf of the UL Hospitals Group and the HSE.
Steed told the hearing Wednesday that she had “wrongly and regrettably presumed” that her advice to staff on the night Aoife presented, which she said would have helped ease overcrowding, had been immediately acted upon, when in fact it had not.
Aoife arrived at UHL on 17 December, 2022, along with a GP letter querying sepsis, and she should have been seen by a doctor within 15 minutes.
However, Aoife was not triaged for an hour and 15 minutes; she was not examined by a doctor for 12 hours; and she was not given antibiotics, which the inquest heard would have saved her life, until 15 hours and 15 minutes after she had first presented at the hospital.
Steed said she was available to UHL staff by telephone “to provide support and advice”, but her role did not require her to attend the hospital in person.
She admitted she was never on the hospital site throughout Aoife’s tragic hospital presentation but she said she was not required to be.
She said she received one telephone call on the night – at 10.33pm – from the hospital’s on-call assistant director of nursing Patricia Donovan, who informed her there were 81 patients waiting to be seen in the Emergency Department (ED).
Steed said Nurse Donovan also told her that the on-call ED consultant, Dr Jim Gray, and a paediatric consultant had both declined a request by ED clinical nurse manager, Katherine Skelly, to attend the department to help ease the overcrowding.
The paediatric consultant did eventually arrive at the hospital and spent two hours helping to tackle the growing backlog of patients, however Dr Gray had replied he was available to attend emergency situations but not to patient volume.
Steed said she sent a text to the UHL’s clinical director of medicine (CDM) highlighting Dr Gray’s refusal to attend, but she said she “did not receive a response” until the following day.
Steed alleged the CDM texted her back that “one person coming in (to the emergency department) wasn’t going to make a difference” to the overcrowding crisis.
Steed said the words “emergency” “chaos” and “war-zone”, used by several nursing staff in their evidence to the inquest, were “not used” to her on the night Aoife presented at the hospital with life-threatening sepsis.
She said she was not made aware of Aoife’s presence at UHL until the following day, Sunday, 18 December.
She said that on this night she had advised the hospital that its surgical day ward be opened for seven beds; that ward 8b be used for four ED fracture patients; that four more ED patients be transferred to ward 3d; to use 6 vacant beds and surge, meaning to send ED patients on trollies to each ward, and to utilise vacant trollies from endoscopy or the cath lab.
Steed said she was told the chief director of nursing had been informed of the overcrowding situation.
She repeated that she did not follow up with staff on Saturday night as she had “wrongly” presumed her advice would be followed.
However, she stressed her role was an advisory one and she could not order staff to make any clinical changes at the hospital.
She said she also “cannot compel consultants to attend” when they were asked and refused.
She said she had “escalated” the refusal of the consultants to clinical managers.
By 11.30am the day after Aoife arrived at the hospital there were 170 patients in the ED.
Steed said she contacted the hospital’s chief clinical director about possibly cancelling scheduled surgeries and using Nenagh Hospital and St. John’s hospital, Limerick for surge capacity beds.
She said she also sought to have the hospital’s acute fracture unit opened up to alleviate the weekend overcrowding but “there was not available staff to attend the unit”.
She said she also messaged the chief radiology registrar regarding prioritising CT scans for orthopaedic patients in order to escalate patent transfers out of the ED to Croom Orthopaedic Hospital hospital but “did not receive a reply”.
She said she maintained contact with hospital staff throughout the weekend and was only told about Aoife Johnston on Sunday.
She said she was informed Aoife had died and that she would need to attend “an unscheduled Serious Incident Management Team meeting asap”.
Under questioning from Damien Tansey, senior counsel and solicitor for the Johnston family, Steed denied she had “executive” powers at UHL. She said decisions were made by managers in higher ranks.
Tansey said the Johnston family were “extremely concerned and worried” that UHL staff were trying to “pass the buck” in respect of the circumstances of Aoife’s death.
Ciara Daly, barrister representing Steed, said she rejected this and that the witness was fully cooperating with the inquest. Daly asked coroner John McNamara that the comment be “struck from the record”.
McNamara did not order it from the record but he asked Tansey to “refrain” from repeating it.
Steed said she fully accepts an unprecedented overcrowding emergency was unfolding in the ED on the night Aoife was brought in there, but she argued that “at the time I didn’t know”.
She said she was aware of the high patient numbers in the ED but she did not know how many were category 2 patients, dangerously ill patients, including Aoife.
She said the only time she might have been expected to be on site at UHL was in the event of a “major emergency” but she said that overcrowding “is not the criteria for a major emergency”.
Steed said that the advice she had given, on the night Aoife was brought to the hospital, would have “taken 30 or 40 patients out of the ED”.
Only 12 patients were moved out of the ED on the night, the inquest heard.
Steed agreed with Tansey that whatever she did do (on the night) “didn’t help matters”.
She said the concerns she escalated to higher management about the two consultants refusing to attend the ED also “didn’t help”.
She agreed that despite her efforts to help the overcrowding crisis in the ED, “it got dramatically worse”.
Steed also agreed that overcrowding, staff deficits, inefficient patient flow and a lack of bed capacity had “adversely impacted” the functioning of the ED and the provision of safe care for patients.
“That was the situation at the time of this tragedy,” Tansey put it to the witness.
steed replied: “Yes”.
“And that was the situation long after this tragedy,” Tansey continued.
“Yes”, Steed said.
“It’s the situation even now, the whole country knows it,” Tansey concluded.
Steed wept as she told the inquest she had been haunted by Aoife’s death.
“I won’t forget Aoife or her beautiful face,” she said, weeping in the witness box.
At this point, Aoife’s sister Meagan, became emotional and retorted before walking out of the hearing: “No, we are the ones who have to go home without seeing Aoife again”.
The inquest is due to conclude on Thursday.
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