Aoife Johnston inquest: Limerick hospital staff describe being ‘haunted’ by teenager’s death

Doctor says medicine that could have saved teenager’s life ‘wasn’t given as immediately as it should have’

A doctor who treated Aoife Johnston (16) before her death at University Hospital Limerick (UHL) wept in the witness box at the teenager’s inquest, telling Limerick coroner John McNamara that the emergency department at the hospital was “not a safe environment” for patients.

Dr Leandri Card told of how she was trying to manage 191 emergency department (ED) patients on her own, and that she and ED nurses were “overwhelmed” on the night Aoife presented at the hospital.

The South African native, who was working as a senior house officer (SHO) in UHL’s ED, said “every inch of the floor space” was taken up by patients on trolleys when Aoife presented on December 17th, 2022.

“It was like a war zone. It was an impossible situation,” she said.


Dr Card told the inquest, which is being held at Limerick Coroner’s Court, in Kilmallock, that due to overcrowding and pressure on staff, she and other doctors routinely prescribed medication for ED patients without first seeing or examining them.

“It happens on every shift, on every day,” she said.

Dr Card agreed with Damien Tansey, senior counsel and solicitor representing the Johnston family, that this was “not best practice”.

She said that despite prescribing antibiotics for Aoife at 6.40am on December 18th, to treat suspected meningitis, the teenager did not receive this medication for an hour and 15 minutes.

Dr Card said the medicine, which it was heard would have potentially saved her life, “wasn’t given as immediately as it should have”.

The witness said she did not have access to where medicines were kept. Prescribed drugs were normally administered by nurses, but Dr Card indicated she was not blaming anyone for the delay. “It is common that it doesn’t happen as immediately as it should, as the nurses are overwhelmed.”

She agreed she was still “haunted and troubled” by Aoife’s death.

She said doctors routinely “don’t have enough time” to read patient medical charts before prescribing medicines to them; instead they have brief exchanges with nurses who advise them of the patient’s symptoms.

Dr Card also agreed she was “by herself” as the only SHO on the ED floor on the night Aoife was brought in by her parents, and she was trying to “manage 191 patients”.

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Wiping away tears, Dr Card described as “intolerable” the situation in the Limerick ED.

Aoife presented at UHL at 5.40pm on December 17th, 2022. The hospital’s protocols on sepsis, which require sepsis-queried patients to be seen urgently, were not followed, the inquest heard.

Aoife was not triaged until 7.15pm that night, and she did not receive antibiotics until it was too late. She died at UHL on December 19th.

Dr Card agreed she had been severely emotionally impacted by Aoife’s death.

She said it was “instrumental” in her decision to quit the HSE to work in a private health clinic, and she said she has not worked in an emergency department since.

Nicola Quinn, assistant director of nursing at UHL, agreed with Mr Tansey that conditions in the ED were “positively dangerous” for patients.

Ms Quinn agreed there was “no handover” of Aoife’s case when staff came on duty on December 18th, which Ms Quinn described as “a miss”.

She accepted she had a “managerial role in the emergency department”, and was responsible for assisting nurses in the ED, but she argued she had not been aware of Aoife nor her condition on December 17th, when time was of the essence in saving her.

She said that a “constant conveyor belt” of “category two” patients, which were deemed to be dangerously ill patients and which included Aoife, as well as multiples of patients with bone fractures due to falls on ice during a severe weather alert, had “overwhelmed” staff.

UHL senior clinical nurse manager Alison Nolan agreed with Mr Tansey there had been a “breakdown in communications” among nursing staff in conditions that were like a “war zone”.

Ms Nolan, in reply to Mr Tansey, said that “undoubtedly” Aoife would have survived had she received the antibiotics she urgently needed more quickly, and which Mr Tansey said had been easily available to staff.

Mr Tansey said it was accepted that “pathogens” that were “fuelling” Aoife’s sepsis, which were traced in her blood, would have been defeated by the antibiotics.

“Aoife Johnston was the sickest patient in the casualty department,” Mr Tansey put it to Ms Nolan.

“In hindsight, yes,” Ms Nolan replied.

Ms Nolan fought back tears as she agreed Aoife’s death had left her “haunted”.