UHL had 14 empty beds on fatal night
Aoife’s family ‘reserve’ right to complain to Medical Council over two doctors
TEENAGER Aoife Johnston’s family are reserving their right to make a complaint to the Irish Medical Council (IMC) against two doctors working at University Hospital Limerick when she died.
Her inquest heard this week that despite medics and nurses giving evidence at the inquest into the 16-year-old’s death about ‘war zone’-like overcrowded conditions, there were 14 empty beds at the hospital while Aoife lay across two chairs as her distraught parents screamed for help.
The family’s barrister told the inquest about the empty beds as he was summing up their arguments for a medical misadventure verdict on the final day of the inquest into the schoolgirl’s death. He also described the evidence given by Dr
Mohammed Hassan was described as ‘unconvincing’. And according to senior counsel Damien Tansey, Dr Nuneeb Shadid’s evidence was so ‘absurd’ it should be disregarded. During the four-day inquest the medic claimed fluids and paracetamol were ‘as important if not more important’ than the antibiotics needed to save Aoife’s life.
The teenager was sent to the hospital because her GP believed that she had developed the life-threatening condition sepsis. But it was another 15 hours and 15 minutes before she was given medication that would have prevented her death. By then it was too late.
Suspected patients with sepsis should be seen by a doctor within ten to 15 minutes of arriving at a hospital.
The risk of death increases with every hour that passes if a patient is not given antibiotics.
But, in his evidence, Dr Shadid claimed that Aoife had been downgraded from a seriously ill category 2 patient to a healthier category 3.
Meanwhile, his colleague Dr Hassan said at the inquest that he could not remember being approached by a senior nurse to attend to Aoife.
When asked this weekend whether the schoolgirl’s heartbroken parents James and Carol would make a complaint against the two medics, their solicitor and barrister Damien Tansey said: ‘The family
are reserving their position in relation to all other matters including the filing of complaints or other matters concerning individual persons. They have issued a number of civil actions.’
Asked last night about the two doctors, the hospital declined to comment.
Instead, a spokesman for the hospital referred to the statement released by HSE boss Bernard Gloster hours after a coroner recorded a verdict of medical misadventure.
In it, the health boss said he would decide what to do following the completion of an independent inquiry being prepared by former Chief Justice Frank Clarke.
This silence from the hospital was criticised this week by sources who work there, one of whom said: ‘The hospital executives, they’re lying low. They haven’t even issued a statement... The HSE put out a statement. The minister, the family... [but] the hospital didn’t. You
wonder why that is?
‘There’s a civil case obviously but... they knew this was coming down the tracks. That was a bit strange that they didn’t make any comment. There is a solution. Ironically, there is money going into the health service. It’s how it’s being spent.
‘The key thing for overcrowding, to try and stop these situations occurring, is to add more beds into the hospital.
‘UHL needs at least 300 more beds on top of what we have. But it’s a big outlay. Each bed costs a million,’ they said. ‘You have a lot of people, who aren’t the ones ending up in the coroner’s court, in charge of the hospital.’
Tragic Aoife Johnson died at University Hospital Limerick on December 19 2022.
Two days earlier, she had gone there with her parents with a letter from a GP. It stated the schoolgirl had suspected sepsis.
And at the inquest into her death, held over four days this week, evidence was given about chaotic scenes at the Limerick hospital.
Experienced nurse Katherine Skelly, a clinical nurse manager at the emergency department at UHL until the night Aoife died, said the hospital was overwhelmed because freezing weather conditions had led to several people falling and fracturing limbs.
Describing how trolleys were lined up so closely together that they even blocked doors, she compared conditions to being like those in a war zone.
The nurse with 23 years’ experience explained: ‘Paediatrics was grossly overcrowded. The seven bays in Resus were all full, plus
‘They knew this was coming down the tracks’
‘It was a major incident status in my opinion’
there were seven more patients there on the floor space. Some were attached to defibrillators.
‘We were in a crisis situation. It was a major incident status in my opinion,’ she said.
In an SOS call to a more senior nurse manager, Ms Skelly recalled saying: ‘This is a major emergency, we need help.’
She told the inquest that she requested for trolleys to be sent from the Emergency Department onto wards. But she claimed this was not done.
And according to the experienced nurse manager, she told her superiors that the department was ‘clinically unsafe’ and that ‘the risk to patient safety was at a level I had not encountered before’.
When nurses finish their shift they routinely inform their colleagues coming on duty about patients.
But on that fateful weekend at University Hospital Limerick, nurses were ‘constantly inter
rupted by patients and patients’ families’ demanding care.
As a result none of the nurses coming on duty were briefed about Aoife – who was described by Mr Tansey as the most seriously ill person at the Limerick hospital.
Indeed, such was the level of chaos as nurses tried to brief their colleagues about patients, that security guards had to be called to deal with hostile patients and their families.
Ms Skelly was one of two staff who decided to hand in her notice after Aoife’s death.
The other medic who resigned was Dr Leandri Card. The South African doctor was described as the ‘most junior’ medic on duty at the hospital when Aoife was admitted.
And it was her decision to prescribe the antibiotics that could have saved the Co. Clare teenager’s life. She made the decision 15 hours and 15 minutes after Aoife had arrived at the hospital.
But it took more than an hour later for nurses to give the schoolgirl the medication.
However, by then it was too late and the chance of saving the young girl’s life had been lost.
Before a verdict of medical misadventure was issued on Thursday afternoon, emergency medical consultant Dr Jim Gray described the Limerick hospital as a ‘death trap’.
The consultant was on call on the night Aoife was admitted, and he told the inquest that when contacted by staff about the chaotic scenes at the hospital’s emergency department, he was asked to come in because of ‘overcrowding’.
‘It’s always chaotic, it was a death trap’
According to Dr Gray, he had been in the hospital already that day until about three o’clock and was due to go back in the following morning.
But he insisted that if he had been told about Aoife Johnston’s condition, he would have gone back into the hospital.
Dr Gray added: ‘It was getting worse as the day went on. It’s always chaotic. It was a death trap. It was grossly overcrowded and it was grossly dangerous. I would have been in communication with the team on the ground.’
Questioned about his dealings with the manager on call that night, Fiona Steed – who now is one of Health Minister Stephen Donnelly’s advisers at the Department of Health – Dr Gray added: ‘I did not have any conversation with the executive on call or the management team.’
‘In fairness to Nurse Skelly, she had an impossible job that night.’