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

An inquest into the death of Aoife John‐ ston, the 16-year-old who died from meningitis at University Hospital Limer‐ ick 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 Uni‐ versity Hospital Limerick two days pre‐ vious 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 Cour‐ thouse 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 par‐ ents brought her to the hospital after being referred by a GP, due to the im‐ mense pressure on staff .

He said that he was not made aware of any specifi c cases and that he worked in the hospital's clinical decision unit throughout the day on Sunday, Decem‐ ber 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 pa‐ tient, 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 "consis‐ tently 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 deliv‐ ered the verdict of medical misadven‐ ture 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 rec‐ ommendations related to the future management of suspected sepsis pa‐ tients at University Hospital Limerick. He also issued recommendations related to how the hospital can trigger an esca‐ lation of services during emergency sit‐ uations such as Johnston's. 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 sis‐ ter 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 off ered his condolences to the Johnston family.

"I wish to off er my sincere condolences to Aoife's parents and sisters who tragi‐ cally 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 dif‐ ficult 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 enor‐ mous loss the Johnston family has expe‐ rienced."

Donnelly said he will ensure that McNa‐ mara's recommendations are "fully con‐ sidered," adding that he will also consid‐ er 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 al‐ so extended his "heartfelt sympathy" to the Johnston family on Thursday. "I want to take this opportunity to re‐ state for the record today our unequivo‐ cal 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 recom‐ mendations into account.

"I know we have considerable work to do to ensure that the people of the mid‐ west, and the staff of University Hospi‐ tal Limerick, have a service they can feel confi dent 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."