Mr Justice Frank Clarke, an independent investigator, has stated that the tragic demise of 16-year-old Aoife Johnson at University Hospital Limerick in 2022, could have been “almost certainly preventable”. Here is how the events unfolded after Aoife was admitted to the hospital, as described in the investigator’s report:
On Saturday the 17th of December:
5.39pm: Alongside her parents, Aoife goes to the emergency department (ED) with a referral letter from an out of hours GP service suggesting sepsis (a life-threatening condition caused by a response to infection from the body).
7.13pm: Aoife is evaluated by a nurse A who places her in triage category 2, meaning gravely ill. Nurse A tries to direct Aoife to the resuscitation or ‘resus area’ due to severity of the sepsis, however, a Registrar claims it is full, and instead, she is sent to Zone A of the ED. Nurse B, on the night shift, reports that she is not informed about Aoife’s possible sepsis.
It took 13½ hours after her arrival at the Limerick hospital to administer Aoife with antibiotics for sepsis. The hospital has been criticised for its ‘management issue’, resulting in overcrowding.
8.25pm: Aoife is given Paracetamol, Ondansetron and Zofran by Dr A.
10.30pm: Aoife’s father asks for a trolley for his daughter, but none are available.
11.50pm: Nurse B discovers Aoife in distress and vomiting. A doctor orders anti-nausea medications and IV fluids.
At midnight: Aoife is relocated to a trolley.
On Sunday the 18th of December:
1.40am: Nurse B is informed of Aoife’s vital signs and consults with Dr B in Resus. Intravenous Keral, a painkiller, is prescribed for Aoife.
4am: Nurse B checks on Aoife and speaks with Dr C in Resus, who advises continuing with paracetamol. There’s disputing evidence as to whether an antibiotic for Aoife was called for by the nurse.
4.30am: Nurse B shares her worries about Aoife with Nurse C.
At 5.45 in the morning, Nurse B broaches Aoife’s condition to Dr D. In response, Dr D decides to prioritise Aoife above other patients in category 2. Following this, Dr D assesses Aoife’s case, orders a dose of antibiotics and communicates her situation to the medical team on duty.
Arriving at 7.15am, the prescribed antibiotics and steroids are given to Aoife. Half an hour later, Aoife’s mother seeks assistance from the nurse’s desk.
As the clock strikes 8am, Aoife exhibits signs of distress and agitation, prompting her to be transferred to the resuscitation department. By 9am, Aoife is under sedation and undergoes a CT scan before being moved to the ICU.
Later in the afternoon, at approximately 3.20pm, her parents are informed about the results from the second CT scan and are warned about the potential risk of brain death. Shortly after, at 3.31pm, Aoife’s death is announced whilst her family is present.
The review by the investigator, brought forth some ambiguity. It remained uncertain whether speedy administration of the prescribed antibiotics at 7.15am could’ve prevented Aoife’s tragic end, considering her critical condition at that point.