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Aoife Johnston (16) died of sepsis at a crowded University Hospital Limerick in December 2022.
Inquest

UHL ED was 'dangerous' for patients on the night Aoife Johnston died, inquest hears

Nicola Quinn agreed there was “no handover” of Aoife’s case when staff came on duty on 18 December, which she described as “a miss”.

LAST UPDATE | 23 Apr

AN ASSISTANT DIRECTOR of nursing at University Hospital Limerick, giving evidence today at the inquest into Aoife Johnston’s death, agreed that the environment inside UHL’s overcrowded emergency department was “dangerous” for patients as Johnston waited more than 12 hours for life-saving antibiotics, which it was heard were not administered in time.

Aoife, 16, from Shannon, Co Clare, died at UHL on 19 December 2022, following a series of delays in her treatment, the inquest which is being held at Limerick Coroners Court, Kilmallock, heard.

Aoife presented at UHL on 17 December, along with with a GP referral letter that queried “sepsis”, a life-threatening blood infection, which required “urgent” attention.

UHL’s sepsis protocols, requiring patients to be seen by a doctor within 15 minutes, were not followed.

Aoife was not triaged until an hour and 15 minutes after first presenting.

When she eventually made it to the emergency department, she had to wait more than 12 hours to be examined by a doctor.

A number of staff wept as they gave evidence to the inquest of struggling to cope with an “unprecedented” wave of seriously ill patients, that included Aoife.

And, when a doctor eventually signed off on antibiotics for Aoife, the drugs were not administered for another hour and half.

Aoife “deteriorated” and died after her brain swelled and she was no longer responsive.

Damien Tansey, senior counsel and solicitor representing the Johnston family said it turned out that Aoife was the “sickest patient” in UHL, but he said that staff coming on duty on 18 December were not immediately aware of her condition because there was “no handover” of her patient file.

Nicola Quinn, UHL assistant director of nursing, agreed with Tansey that conditions in the ED were “positively dangerous” for patients.

Quinn agreed there was “no handover” of Aoife’s case when staff came on duty on 18 December, which Quinn described as “a miss”.

She accepted she had a “managerial role in the emergency department”, and was responsible for assisting nurses in the ED, but she argued she had not been aware of Aoife nor her condition on 17 December, when time was of the essence in saving her.

She agreed with a suggestion by Tansey’s that a lack of communication about Aoife during the patient handover was “entirely unsatisfactory”.

She said that a “constant, conveyor belt” of “category two” patients, which were deemed to be dangerously ill patients and which included Aoife, as well as multiples of patients with bone fractures due to falls on ice during a severe weather alert, had “overwhelmed” staff.

Quinn said she was not aware at the time that UHL had an escalation plan in the event of an influx of patients because of the bad weather.

She said “since” Aoife’s death an escalation plan had been in force when required.

Quinn said the situation in the ED at the time Aoife presented was “untenable”, but she argued she had “exhausted” ways of trying to find additional staff to ease the burden on nurses.

When asked by Tansey if she agreed there were trollies everywhere which was meant a “dangerously risky” ED, she replied: “I would (agree), of course”.

In her deposition, ED nurse Ciara McCarthy said she made three attempts to get senior clinicians to examine Aoife but was told they were too busy and to continue giving Aoife paracetamol and anti-vomiting medication.

‘Breakdown in communications’

Quinn agreed with Tansey that this course of action was “totally ineffective” for Aoife’s condition, and that “smarties” would have had had as much impact.

UHL senior clinical nurse manager, Alison Nolan, said she was “unhappy” that two on-call consultants had been asked to attend the ED but both initially refused to do so – one changed their mind and made a big impact on one specific area of the ED, she added.

Nolan said she was not made aware of Aoife or her sepsis.

She agreed with Tansey there had been a “breakdown in communications” among nursing staff in what were “war-zone” like conditions.

Nolan, in reply to Tansey, said that, “undoubtedly” Aoife would have survived had she received the antibiotics she urgently needed more quickly, and which Tansey said had been easily available to staff.

Tansey said it was accepted that “pathogens” that were “fueling” Aoife’s sepsis, which were traced in her blood, would have been defeated by the antibiotics.

“Aoife Johnston was the sickest patient in the casualty department,” Tansey put it to Nolan.

“In hindsight, yes,” Nolan replied.

Nolan said “site risk assessments” as well as handovers were conducted in the ED at the time, but none of these mentioned Aoife.

Nolan fought back tears as she agreed Aoife’s death had left her “haunted”.

She said there should have been more “clinical cover” in the ED and that senior clinicians should have shown more “leadership” in attempting to ease the pressure in the ED.

Nolan also agreed the 12 hours Aoife had waited for life-saving antibiotics was “dangerous and utterly unacceptable”.

‘Not a safe environment’

Earlier, a doctor who treated Aoife prior to her death at UHL wept in the witness box at the teenager’s inquest.

Dr Leandri Card told the Limerick Coroner, John McNamara, that the emergency department at UHL was “not a safe environment” for patients and how she was trying to manage 191 ED patients on her own.

The South African native, who was working as a Senior House Officer (SHO) in UHL’s Emergency Department said “every inch of the floor space” was taken up by patients on trollies when Aoife presented on 17 December 2022.

Dr Card said she and ED nurses were “overwhelmed” on the night Aoife presented at the hospital.

“It was like a war-zone. It was an impossible situation,” she said.

Dr Card told the inquest which is being held at Limerick Coroner’s Court, in Kilmallock, that due to over-crowding and pressure on staff, she and other doctors routinely prescribed medication for ED patients without first seeing or examining them.

“It happens on every shift, on everyday,” she said.

Dr Card agreed with Damien Tansey, senior counsel and solicitor representing the Johnston family, that this was “not best practice”.

Dr Card said it was the norm and the only way patients would get medication as quickly as possible, because doctors were too busy dealing with patients.

“It’s not a safe environment, you do what you have to do, it’s not best practice.”

When asked by Tansey if this practice would give rise to “adverse outcomes” for patients, Dr Card replied: “Definitely”.

She said that despite prescribing antibiotics for Aoife at 6.40am on 18 December, to treat suspected meningitis, Aoife did not receive this medication for an hour and 15 minutes.

Dr Card said the medicine, which it was heard would have potentially saved her life, “wasn’t given as immediate as it should have”.

The witness said she did not have access to where medicines were kept.

Prescribed drugs were normally administered by nurses, but Dr Card indicated she was not blaming anyone for the delay: “It is common that it doesn’t happen as immediately as it should, as the nurses are overwhelmed.”

She agreed she was still “haunted and troubled” by Aoife’s death.

She said doctors routinely “don’t have enough time” to read patient medical charts before prescribing medicines to them, instead they have brief exchanges with nurses who advise them of the patient’s symptoms.

Dr Crandall also agreed she was “by herself” as the only SHO on the ED floor on the night Aoife was brought in by her parents, and she was trying to “manage 191 patients”.

She said a severe weather episode had “exacerbated” overcrowding in the ED and that “Category Two patients”, include Aoife, who are regarded to be seriously ill patients, were “deteriorating” due to lengthy waiting times to see a doctor.

The inquest heard that staff were not aware of any plans at UHL to implement measures to mitigate patient flow despite the hospital having prior notice of the weather alert.

Dr Card said the recommended time for a CAT 2 patient, which included Aoife, to see a doctor is between 10 and fifteen minutes.

However, Aoife languished for 12 hours across two chairs before being seen by Dr Card. There were no trollies for her to rest on and her parents said she was in “agony” as they contoured to call for “help” but they said “there was no help”.

An ‘intolerable’ situation in the Emergency Department

Wiping away tears, Dr Card described as “intolerable” the situation in the Limerick ED.

She said other CAT 2 patients were waiting longer than Aoife – some were waiting an average of 19 hours to see a doctor, and Category 3 patients were waiting 39 hours.

Aoife presented at UHL at 5.40pm on 17 December 2022. The hospital’s protocols on sepsis, which require sepsis queried patents to be seen urgently were not followed.

Aoife was not triaged until 7.15pm that night, and she did not receive antibiotics until it was too late. She died at UHL on December 19.

Dr Card said she examined Aoife at 6am, December 18th, 12 hours after Aoife had presented with a doctor’s referral letter querying sepsis, a life-threatening condition requiring regent treatment.

The doctor wept and took several deep inhales of breath to try to compose herself while giving evidence. She agreed she had been severely emotionally impacted by Aoife’s death and that the teenager’s death had led to her quitting the HSE.

Dr Card said the ED and adjoining Resus (resuscitation room) were “full up” of trolleys that were blocking doorways. She said: “There was no space, in, our out.”

She agreed there was not enough staff and too many patents which had created a perfect storm in the ED.

Dr Card said Aoife’s death was “instrumental” in her decision to quit the HSE to work in a private health clinic, and she said she has not worked in an emergency department since.

The doctor said she had scanned Aoife’s patient file prior to seeing her first at 6am on 17 December, but she said had not seen the GPs referral letter at this stage, in which the GP indicated he suspected Aoife was suffering with sepsis.

The inquest continues this afternoon and is scheduled to run until Thursday.

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