Manager’s advice to UHL staff ‘not followed through’
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SEPSIS victim Aoife Johnston waited 15 hours for antibiotics which could have saved her but they arrived too late, the inquest into her death heard yesterday.
The 16-year-old was brought to University Hospital Limerick’s A&E before 5pm on December 17, 2022, having being referred by her GP with suspected sepsis.
Readily-available antibiotics were not administered until after 7am the next day and hospital protocols on sepsis patients being seen by a doctor within 15 minutes were not followed.
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.
Aoife’s brain had swollen as she waited for help while vomiting and in agony and she 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.
Limerick Coroner’s Court was told there was a lack of ED doctors, consultants refused to attend the ED when called by desperate nurses.
OVERCROWDING
Fiona Steed, who was the hospital’s general manager and “executive on call” on the night Aoife presented, said advice she had given to staff on the night to try to alleviate the overcrowding was not followed through.
Ms Steed, who left UHL to work at the Department of Health, broke down in the witness box and told how, despite having a managerial post, she did “not have powers” to compel staff to do what she asked.
Ms Steed wept and apologised to Aoife’s family for the circumstances of her death.
She testified she had “wrongly and regrettably presumed” 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.
The witness admitted she was never on the hospital site throughout Aoife’s presentation but she said she was not required to be.
Ms Steed added she received one phone 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 A&E.
She said Nurse Donovan also told her the on-call A&E consultant, Dr Jim Gray, and a paediatric consultant, had declined a request by clinical nurse manager Katherine Skelly, to
No, we’re the ones who have to go home without seeing Aoife again
AOIFE’S SISTER MEAGAN
attend to help ease the overcrowding. Mr Gray did eventually arrive and spent two hours helping to tackle the growing backlog.
However, he had replied he was available to attend emergency situations but not to patient volume.
Ms Steed said she texted UHL’S clinical director of medicine highlighting Mr Gray’s refusal to attend, but she said she “did not receive a
response” until the following day. Ms Steed alleged the CDM replied that “one person coming in wasn’t going to make a difference”.
COMPEL
She said she also “cannot compel consultants to attend” when they were asked and refused.
Mr Tansey said the Johnston family were “extremely concerned and worried” that UHL staff were trying to “pass the buck” over Aoife’s death.
Ms Steed’s counsel Ciara Daly said she rejected this and the witness was fully cooperating with the inquest.
Ms Steed wept as she told the inquest she had been haunted by Aoife’s death. She said: “I wont forget Aoife or her beautiful face.”
At this point, Aoife’s sister Meagan, became emotional and said before walking out: “No, we are the ones who have to go home without seeing Aoife again.” The inquest continues.