Aoife Johnston: A story of systematic hospital failures

16-year-old Aoife Johnston died at University Hospital Limerick (UHL) on Monday 19 December 2022, two days after presenting at the emergency department with symptoms of suspected sepsis.

The Leaving Cert student, from Shannon, Co Clare, died from meningitis on the afternoon of 19 December in the hospital's ICU after her condition worsened significantly over those two days.

It was 12 hours before she was seen and assessed by a doctor who prescribed antibiotics which could have saved her life, and 14 hours before those drugs were administered and she was transferred to ICU.

An inquest into her death heard of chaotic overcrowding and an unsafe environment with staff trying to cope with over 190 patients in the ED that Saturday night.

The UHL ED was described by staff as "like a war zone" and "a death trap" with every conceivable space taken up, such was the extent of the overcrowding.

The night of 17 December 2022, when Aoife Johnston was first brought in by her parents, was also a Saturday night, the weekend before Christmas and the weather was very poor leading to a lot of of patients presenting with fractures.

There was not even a trolley available for the sick teenager and her parents had to put her on a makeshift bed made up of two chairs and covered with a blanket.

By the time the antibiotics were administered it was too late and sepsis had taken hold, and she died on the afternoon of 19 December, a day after she had been transferred to ICU.

An internal review of the circumstances surrounding her care was ordered by the new HSE boss Bernard Gloster, which found there were missed opportunities and a breach of the national sepsis guidelines.

Those guidelines state that the care of patients suffering with suspected sepsis must be escalated and she should have been seen by a doctor within 15 minutes of that assessment.

On 18 December 2023, just one day short of the first anniversary of her death, Mr Gloster appointed former chief justice Frank Clarke to carry out an investigation, saying there was a need for accountability over what happened to Aoife Johnston and the circumstances which lead to her death.

A four-day inquest into her death returned a verdict of medical misadventure.

Coronor John McNamara said it was clear there were systemic failures, missed opportunities and communication breakdowns at UHL- saying it was clear that Aoife Johnston should have been seen and treated, and that was without doubt.

The Irish Association for Emergency Medicine said: "Quite simply the delays in her receiving essential care should never have happened."

Mr Clarke submitted his report to Mr Gloster in July.

Three senior members of the UHL management team are currently on administrative leave as a result of the findings. Two further staff are also facing possible disciplinary proceedings.