University Hospital Limerick (UHL) was “like a warzone” on the night 16-year-old Aoife Johnson died in December 2022, a doctor who treated the tragic teenager has told the inquest into her death at Limerick Coroner’s Court.
Medical staff who were present on the night the schoolgirl died at the Limerick Hospital are among the 23 witnesses who will give evidence at Kilmallock’s Coroner’s Court, which began on Monday.
Dr Leandri Card, a doctor originally from South Africa, wept in the witness box on Tuesday, telling the inquest that the hospital was “like a war zone; it was an impossible situation” on the night Ms Johnston died. She agreed that 16 months after the tragedy, she was still “haunted and troubled” by the teen’s death.
She told the second day of the inquest that she had been severely emotionally affected by Aoife’s death, and that the tragedy had been “instrumental” in her quitting her role in the HSE to work in a private health clinic.
Aoife had been left across two chairs, which had been pulled together by her parents to create a makeshift bed, for 12 hours before she was seen by Dr Card. At the time, there were no trolleys available for her to lie on, with her parents telling the inquest their daughter was in “agony” as they appealed for help. “There was no help,” they said.
The fifth year student had attended the hospital with a GP referral letter which advised that she required urgent treatment for suspected sepsis.
The South African native was working as a Senior House Officer (SHO) in UHL’s Emergency Department (ED) on the night the Shannon schoolgirl presented at the hospital.
During the second day of the inquest, Dr Card told Limerick coroner John McNamara that the ED was “not a safe environment” for patients, as she described attempting to manage 191 ED patients of her own. ED nurses were “overwhelmed” on the night in question, Dr Card said. The doctor also recalled how “every inch of floor space” was taken up by patients on trolleys on the night of December 17th, 2022.
A further report into the teenager’s death is currently being led by former chief justice Frank Clarke, following a systems analysis review into the tragedy. An inquest into Aoife’s death was ordered by coroner John McNamara, which is expected to take four days to complete in Kilmallock Courthouse, Limerick, this week, concluding on Thursday.
The doctor, who became emotional while giving evidence, said that overcrowding and pressure placed on staff meant that she and other doctors routinely prescribed medication for ED patients before first seeing or examining them. Dr Card admitted this was normal practise, and that it was the only way patients would access medication as quickly as possible – as doctors were busy dealing with the influx of patients.
“It happens on every shift, on every day,” she said, while agreeing with senior counsel and the solicitor representing the Johnston family, Damien Tansey, who said that this was “not best practice.”
“It’s not a safe environment, you do what you have to do, it’s not best practice,” Dr Card said.
The inquest heard that despite Aoife being prescribed antibiotics at 6:40am on 18th December in order to treat suspected meningitis, she did not receive the medication for another hour and 15 minutes. The inquest heard that the medication would have potentially saved the young woman’s life, with Dr Card saying that it was not given “as immediate as it should have” been.
Regarding the delay in giving the teenager the medication, which Dr Card said was normally administered by nurses, the doctor said: “It is common that it doesn’t happen as immediately as it should, as the nurses are overwhelmed.”
The doctor also agreed that she was “by herself” on the ED floor that night, as the only SHO present. She said the situation in the Limerick ED was “intolerable,” and that at the time, other CAT 2 (category 2) patients – those classed as seriously ill – were waiting even longer than the teenager, with some waiting an average of 19 hours to see a doctor.
The inquest also heard that UHL’s own protocols on sepsis were not followed. Dr Card further explained that the recommended time for a CAT 2 patient, such as Aoife, to be seen by a doctor is between 10 and 15 minutes.
The teenager was not triaged until 7:15pm that evening, and by the time she received antibiotics, it was too late. She passed away at UHL on 19th December.
On Monday, Aoife’s parents fought back tears as they recalled how they had desperately begged UHL staff to help their daughter, who was screaming in pain as her condition deteriorated.
Another senior nurse yesterday also testified to the emergency department being “akin to a warzone,” and worse than if there had been a major accident.
“I never worked in accident and emergency again after that weekend,” clinical nurse manager Katherine Skelly said.
“It absolutely broke me professionally and personally that that girl (Aoife) died.”
Aoife’s mother Carol told the courtroom on Monday that while she and her husband told their daughter she was “in the best place,” this ended up not being the case.
“We watched our daughter die,” Carol Johnston said.
“I would not wish it on anyone. God love her. We told her she was in the best place (UHL) but it turned out she was not.”