Doctor tells inquest environment at UHL was a ‘death trap for Aoife Johnston’

Her inquest is now in its fourth day at Kilmallock courthouse in Limerick before Coroner John McNamara. Several medical staff have given evidence since Monday — many of them have described the emergency department that night as a “war zone”.

Nurse Patricia Donovan told the inquest on Wednesday that two consultants were contacted to come in to help with the 191 patients in the overcrowded unit, however one declined and the other, Dr Fasih Khan, came in for two hours.

On Thursday morning, Dr James Gray gave evidence that he was the emergency consultant on call from 17 to 19 December, 2022, when Aoife Johnston was referred by her GP to the hospital with suspected sepsis. He described the emergency department that night as “dysfunctional and chaotic”.

“You have good staff working in a very poor environment,” he said.

A dysfunctional environment, chaotic scenes of overcrowding, patients back-to-back on trollies, double lines in corridors.

“It would be like an airplane that is full, passengers on seats, and the aisles are full of patients and every conceivable space is full of patients. You can imagine how that plane would function, it wouldn’t,” he said.

He told the inquest there was “leadership” that night but “unfortunately the leadership wasn’t able to manage the situation”. “The only thing that would have worked that night was to activate the major emergency plan. That’s a call that is made by the executive on call,” he said.

When asked by Damien Tansey SC for the Johnston family if that was the executive on-call’s responsibility, Dr Gray replied: “In conjunction with the people on the ground.”

Mr Tansey put it to him that Dr Gray was also “on call”. “I am not part of the executive team” he replied. “I was available to come in on a case-by-case basis, I was available if the major emergency plan was activated and I was available to give advice on the telephone if required, which I did all day.

“Then at 10:30pm I was asked to come in (over the phone) having done a day and I needed to be in in the morning by 8 o’clock, I am not superman,” he said.

Mr Tansey said: “I am not suggesting you are but if you are asked to come in and you are on call, you should be in”. Dr Gray described the situation as “impossible” and that he had been on for 48 hours.

“Guess what, it’s always busy,” he said. “It has been busy ever since. The hospital is the most overcrowded hospital in this state, today.”

Mr Tansey put it to him during his cross-examination that “children were in the arms of their parents” requiring attention and another pediatric consultant came in.

“I was not made aware of the case (of Aoife Johnston),” said Dr Gray. “I had a schedule at 8 the following morning which I couldn’t get out of, there was nobody else to do it.

“I had to make decisions in the early morning. Had I not been there those decisions would not have been made.

“The problem here is there is one consultant on for the entire weekend, I don’t make the rules it’s just the way it was. It’s not good enough. In an ideal world a consultant would be there 24/7.”

He said changes could only happen in the hospital with more consultants and more people to provide care and that contractual changes would have to be made.

Mr Tansey said Aoife Johnston was lying on a makeshift bed put together by her parents and that she was a category two patient and should have been seen between 10 and 15 minutes after her admission.

Dr Gray said: “Ten minutes” and that the situation for Aoife was “unacceptable”. The environment, he said, was a “death trap for Aoife Johnston”.

Dr Gray continued: “The department was unable to function. “What needed to happen was a major emergency plan. It would mean that all of the on-call staff would come in.

There were between 40 and 55 patients who no longer required emergency care. On top of 150 patients that were emergency patients. They had no chance; Aoife Johnston had no chance.

Mr Tansey said the teenager’s condition was treatable and referred to the pathogens that existed in her system which were all amenable to the full spectrum of antibiotics — the inquest was told this on Wednesday.

He described again that she was on two chairs put together by her parents and was crying out in pain.

Dr Gray said she had “no dignity, no privacy, very poor” and he said it was “beyond an emergency, it was an abuse of human rights”.

“Had she been triaged quickly,” he said, “And seen and the sepsis bundle commenced within the hour, as per the protocols, then she would have had a better fighting chance, but she didn’t.”

Mr Tansey said while Dr Gray had agreed with his descriptions of the hospital that night, he should have come in. “You had it in your remit” to escalate the situation to the executive committed. Dr Gray said it was not in his remit.

He continued: “I was not aware of any individual case brought to my attention.” He said that he was at work on Friday, December 17 until 3pm and that the emergency department was “grossly overcrowded and grossly dangerous”.

He said he was in communication with the staff on the ground but did not talk to the executive council.

The inquest also heard there were 67 category two patients across the two zones in the hospital casualty department, the numbers Dr Gray said were “off the scale” and that “the department could not function”.

“Had I known there was a 16-year-old child who entered the emergency department in septic shock, a category two patient who couldn’t get into the rhesus room, I would have come in,” he said.

“The system failed her, the ED failed her” and he said that he “was not asked to come in about a specific case”. He also paid tribute to Aoife as a “beautiful girl” and gave his condolences to her family.

Closing arguments are due to be made on Thursday afternoon as the case comes to a conclusion.