Aoife Johnston: Verdict of medical misadventure returned at inquest

The family of Aoife Johnston want to see another emergency department opened in the Mid-West and never want another family to go through what they went through.

A verdict of medical misadventure has been recorded in the death of the 16-year-old.

Speaking outside Kilmallock Courthouse, Aoife's mother Carol said Aoife was a “happy, easy going girl, happy go lucky” and her father James said she was his “baby girl.”

Aoife's older sister Kate said: “I'll never ever forget Aoife – it kills me all the time that I never got to say goodbye to her.

“That's my baby sister and we never got to see her again.”

READ MORE: Inquest hears UHL was a 'deathtrap' the weekend Aoife Johnston died

Four recommendations were made by the coroner – these included that the recommendations from the SARs report be endorsed, that an appropriate mark be put on the outside of a patient's chart if they present to the hospital with possible sepsis and that the chart be kept in a separate pile until a doctor reviews it, a formal plan of communication among the management channels to be actioned in the case of difficulties with overcrowding and that there be no delay in contacting a member of the executive management team in an emergency situation.

In delivering his verdict, Limerick Coroner John McNamara said there were “systemic failures, missed opportunities and breakdowns in communication.”

He said for the family, they have been “living a nightmare, no doubt, since Aoife's death and revisiting everything I'm sure has been extremely difficult.”

Aoife Johnston's family speaking to press following the four-day inquest ay Kilmallock Courthouse | PICTURE: Brendan Gleeson

“You'll be living with this the rest of your lives,” he added.

“The bottom line is that Aoife should have been seen treated in a timely manner given that the illness she came in with was treatable,” the coroner told the court.

In his closing speech, senior counsel Damien Tansey, recommended a verdict of medical misadventure and this was not opposed by Conor Halpin, representing the UL Hospitals Group or solicitor Ciara Daly, representing Fiona Steed.

He said that when Aoife died on December 19, 2022, it was the week before Christmas.

The youngest of three girls, Aoife woke up on the morning she went into hospital and Mr Tansey said she “went into the kitchen in her jammies, like a lot of children do.”

“That Saturday morning, little did the Johnston family know that in a matter of hours, their beautiful daughter would be dead,” he told the court.

After Aoife saw ShannonDoc and was diagnosed with query sepsis, they went straight to University Hospital Limerick.

“Their encounter with the Limerick hospital was brief, but tragic. It was a dangerous environment for a dangerously ill patient,” he said.

Citing evidence from during the week, he said that time is critical in treating sepsis and that “by the time Aoife was treated, she was beyond recovery, she was beyond repair”.

Mr Tansey said if the hospital had responded when the family had pleaded for help, they might not be in Kilmallock courthouse today.

Solicitor Ciara Daly acting on behalf of Fiona Steed, and Conor Halpin, representing the UL Hospitals Group, both passed on their sincere condolences to the family on their loss and the apologies from the UL Hospitals Group and HSE were reiterated.