An Assistant Director of Nursing at University Hospital Limerick, giving evidence on Tuesday at the inquest into Aoife Johnston’s death, agreed that the environment inside UHL’s overcrowded emergency department was “dangerous” for patients as Ms Johnston waited more than 12 hours for life-saving antibiotics, which it was heard were not administered in time.

Aoife, 16, from Shannon, died at UHL on December 19 2022, following a series of delays in her treatment, the inquest which is being held at Limerick Coroners Court, Kilmallock, heard. Aoife presented at UHL on December 17, along with with a GP referral letter that queried “sepsis”, a life-threatening blood infection, which required “urgent” attention. UHL’s sepsis protocols, requiring patients to be seen by a doctor within 15 minutes, were not followed. Aoife was not triaged until 1 hour 15 minutes after first presenting. When she eventually made it to the emergency department she had to wait more than 12 hours to be examined by a doctor.

A number of staff wept as they gave evidence to the inquest of struggling to cope with an “unprecedented” wave of seriously ill patients, that included Aoife. And, when a doctor eventually signed off on antibiotics for Aoife, the drugs were not administered for another hour and half. Aoife “deteriorated” and died after her brain swelled and she was no longer responsive.

Damien Tansey, senior counsel and solicitor representing the Johnston family said it turned out that Aoife was the “sickest patient” in UHL, but he said that staff coming on duty on December 18 were not immediately aware of her condition because there was “no handover” of her patient file.

Nicola Quinn, UHL assistant director of nursing, 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 18, 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 17, when time was of the essence in saving her. She agreed with a suggestion by Mr Tansey’s that a lack of communication about Aoife during the patient handover was “entirely unsatisfactory”.

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.

Ms Quinn said she was not aware at the time that UHL had an escalation plan in the event of an influx of patients because of the bad weather. She said “since” Aoife’s death an escalation plan had been in force when required. Ms Quinn said the situation in the ED at the time Aoife presented was “untenable”, but she argued she had “exhausted” ways of trying to find additional staff to ease the burden on nurses.

When asked by Mr Tansey if she agreed there were trolleys everywhere which was meant a “dangerously risky” ED, she replied: “I would (agree), of course”.

In her deposition, ED nurse Ciara McCarthy said she made three attempts to get senior clinicians to examine Aoife, but was told they were too busy and to continue giving Aoife paracetamol and anti-vomiting medication. Ms Quinn agreed with Mr Tansey that this course of action was “totally ineffective” for Aoife’s condition, and that “smarties” would have had as much impact.

UHL senior clinical nurse manager, Alison Nolan, said she was “unhappy” that two on-call consultants had been asked to attend the ED but both initially refused to do so – one changed their mind and made a big impact on one specific area of the ED, she added. Ms Nolan said she was not made aware of Aoife or her sepsis. She agreed with Mr Tansey there had been a “breakdown in communications” among nursing staff in what were “war-zone” like conditions.

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 “fueling” 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 said “site risk assessments” as well as handovers were conducted in the ED at the time, but none of these mentioned Aoife.

Ms Nolan fought back tears as she agreed Aoife’s death had left her “haunted”. She said there should have been more “clinical cover” in the ED and that senior clinicians should have shown more “leadership” in attempting to ease the pressure in the ED. Ms Nolan also agreed the 12 hours Aoife had waited for life-saving antibiotics was “dangerous and utterly unacceptable”.