The death of Aoife Johnson (16) in University Hospital Limerick in 2022 occurred in circumstances that were “almost certainly avoidable”, the Independent Investigator Mr Justice Frank Clarke, has said.
The below sequence of events occurred after Aoife’s arrival at the hospital, according to the inspector’s report.
Saturday, December 17th:
5.39pm: Accompanied by her parents, Aoife presents at the emergency department (ED) with a letter of referral from an out of hours GP service querying sepsis (a dangerous condition arising from the body’s response to infection).
7.13pm: Aoife is seen by a nurse A and is assigned triage category 2, meaning seriously ill. Nurse A wants to send Aoife to the resuscitation or “resus area” because of the sepsis concern but a Registrar says it is full and Aoife is sent to Zone A of the ED. Nurse B, on the night shift, says she is not told about the sepsis concern.
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8.25pm: Aoife is administered Paracetamol, Ondansetron and Zofran by Dr A.
10.30pm: Aoife’s father requests a trolley for his daughter but none available.
11.50pm: Nurse B finds Aoife to be nauseated and vomiting. A doctor prescribes anti-emetics and IV fluids.
Midnight: Aoife is moved to a trolley.
Sunday, December 18th:
1.40am: Aoife’s vitals are reported to Nurse B who speaks with Dr B in Resus. Aoife is prescribed intravenous Keral, a painkiller.
4am: Nurse B assesses Aoife and speaks with Dr C in Resus who advises continued paracetamol. Conflict of evidence as to whether nurse requested an antibiotic for Aoife.
4.30am: Nurse B discusses her concerns about Aoife with Nurse C.
5.45am: Nurse B discusses Aoife with Dr D who agrees to see Aoife ahead of other category 2 patients. Dr D reviews Aoife, prescribes antibiotics, and speaks to the on call medical team about her.
7.15am: Antibiotics and steroids administered.
7.45am: Aoife’s mother goes to nurse’s station seeking help.
8am: Aoife distressed and agitated. She is moved to Resus.
9am: Aoife is sedated. Given CT scan and transferred to Intensive Care Unit.
3.20pm: Parents told result of second CT scan and that brain death is a possibility.
3.31pm: Aoife is declared dead with her family in attendance.
In his report the investigator says it is unclear if it would have prevented Aoife’s death if the antibiotics had been administered immediately after being prescribed at 7.15am, given how ill she was at that stage.
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