The parents of Aoife Johnston who died at University Hospital Limerick (UHL), after waiting 12 hours on a chair while dying of sepsis, told her inquest on Monday that they watched her die despite “begging” staff to help.
James and Carol Johnston gave emotional and harrowing evidence at Limerick Coroner’s Court of the final moments of their 16-year-old daughter’s death, on December 19th, 2022.
James Johnston wept and held his face in his hands as he told the inquest that, despite his pleadings for assistance for his daughter, UHL staff “kept giving Aoife paracetamol, and putting ice packs on her legs” but that “they just weren't really helping, there was no help”.
Mr Johnston said Aoife had awoken at their home on Saturday, December 17th, in “great form” but she became “unwell” around midday, and “took some paracetamol and returned to bed”.
Around 3.30pm Aoife vomited and Mr Johnston made an appointment at locum GP service Shannodoc for 4.50pm for Aoife.
Mr Johnston said the on-call doctor, Dr Madlala Mdumiseni, told them that after examining Aoife he was “concerned” for her and he advised they go directly to UHL.
Dr Mdumiseni told the inquest he had formed the view that Aoife was suffering from an “acute infection of sepsis with symptoms worsening”.
Dr Mdumiseni said Aoife “looked clinically unwell”, her heart rate was fast, her blood pressure was low, she was dehydrated, weak and lightheaded.
Dr Mdumiseni said he gave Mr Johnston the referral letter and told him to present it at UHL to ensure Aoife would be seen “as soon as possible”.
However, the inquest heard it was over 12 hours before Aoife was seen by a doctor.
Mr and Mrs Johnstone said they immediately brought their daughter to UHL, arriving at the hospital at 5.40pm.
Carol Johnstone said that on the way to UHL she opened the referral letter “which stated that Aoife had a temperature of 39.5 and that the doctor felt that she might have viral septicaemia and dehydration”.
When they arrived at UHL they handed in the referral letter and were told to take a seat in reception.
Aoife was not seen by a triage nurse – the first point of contact with medical staff – until 7.15pm, an hour and 35 minutes after presenting at the hospital.
James Johnstone said Aoife “vomited twice while waiting” for the triage nurse.
The nurse, he said, “spent approximately five minutes with Aoife” before taking her on a wheelchair to the emergency department which it was heard was overcrowded with trolleys.
“There was no trolley available, so we tried to make a bed for Aoife with two chairs,” Mr Johnstone said.
Aoife’s condition worsened but she did not receive adequate care “until it was too late”, Damien Tansey, senior counsel and solicitor for the Johnstone family said.
Throughout the night Aoife’s skin developed blotches and became discoloured around her left eye.
“Aoife was violently vomiting pure green liquid. I continually begged for help. The response was a brown cup for Aoife to vomit into, and on one occasion a rebuke, ‘I am well aware she is sick, but have 70 other patients to look after’,” Mr Johnston said.
“I was up and down to the nurses all night pleading with them to help my daughter. Aoife was screaming in agony with pain in her right leg and head.”
Mr Johnstone said his daughter’s screams were so loud “that I heard people outside on the trolleys asking the nurses and doctors to help Aoife, and at one point a man said ‘is someone not going to go into that girl’”.
Carol Johnstone said that as her daughter was being brought to the emergency department, she “noticed a huge number of trolleys and I said to the nurse ‘look she's really ill, you're not leaving us here are you? She’s really unwell’”.
She said Aoife was moved from Zone A at the ED to what “appeared to be a storage room as there was PPE gear all over the room”.
“There was no trolley available, so we tried to make a bed for Aoife with two chairs,” Ms Johnstone added.
Aoife’s parents said that, at one point during the night, staff brought Aoife for an X-ray, but that “when Aoife came back, she was very upset and said that the staff were ‘really mean’ to her”.
“She told us that they were giving out to her because she couldn't stand up but by that point Aoife was physically unable to stand”.
Mr Tansey said his clients were adamant Aoife was brought for the X-ray, but he said, UHL had “no record” of the attempted scan.
Aoife was first seen by a doctor at 6am the following morning, December 18th, and was advised she would be treated as if she had meningitis.
At this stage, Aoife was “in agony”, her father said.
“After the doctor left, Aoife started to deteriorate even more. I went out to the nurses station and there were approximately 12 nurses just standing there, and I roared at them to help my f*****g daughter,” Mr Johnstone said.
“At this point, my daughter could no longer communicate. Aoife was taken to resusitation, her limbs were moving involuntarily, I was asked to hold down my daughter's legs so they (doctors) could administer treatment.”
Doctors placed Aoife in an induced coma to reduce swelling on her brain but she was pronounced dead at 3.30pm on December 19th.
Mr Tansey said the head nurse who was in charge of Aoife’s care was presently in Australia, she had prepared a deposition for the inquest, but she was not available to attend the hearing in person or by a Zoom call.
Mr Tansey said all parties had “months” of notice of the inquest date and that it was “inconceivable” that in a modern world with technology that a witness was not available to give evidence or take questions on a Zoom call.
He said it was of “great concern” that the Johnstone family would not have the opportunity to cross-examine the nurse.
Mr Tansey said an external interim report, which was completed into Aoife’s care had been given to the HSE and UL Hospitals Group, but that the Johnstone family were again “concerned” that they still did not see the report and they have had to “rely” on media reports to hear its contents.
Mr Tansey said the Johnstone family were grateful for meetings they had with the chief executive of the HSE, Bernard Gloster, and Minister for Health Stephen Donnelly.
Conor Halpin, senior counsel acting for the HSE, read out two letters of apology on behalf of Mr Golster and Colette Cowan, chief executive of the UL Hospitals Group for admitted “failings” in Aoife’s care which led to the “catastrophic” outcome of her death.
The Johnstone family also acknowledged that the nature of Aoife’s death had personally impacted Mr Gloster. Mr Tansey said: “He [Mr Gloster] was clearly emotionally moved by the nature of their tragic loss.”
Mr Tansey said the Johnstone family were concerned Ms Cowan, who would have clear knowledge of the running of the emergency department was not a witness at the inquest.
Coroner John McNamara said Ms Cowan was not asked to provide a deposition and that depositions provided by UHL staff who were directly involved in Aoife’s care would be heard.
Carol Johnston concluded her deposition, telling the court: “I continually begged for help. We watched our daughter die, I wouldn’t wish it on anyone.”
“God help her, we told her she was in the best place, but it turned out she wasn’t.”
The inquest is scheduled to run for four consecutive days.
