A verdict of medical misadventure has been returned at the inquest into Aoife Johnston's death at University Hospital Limerick.
The 16-year-old died at the hospital on December 19th 2022.
She presented at the facility with an on-call GP referral which queried sepsis; however she wasn't seen by a doctor for 12 hours.
During the hearing a doctor who treated Aoife before her death described University Hospital Limerick as a 'war-zone'.
Dr Leandri Card said she has quit working in the HSE because of Aoife's death and admitted it was bad practice that doctors gave medication to Emergency Department (ED) patients without examination.
Dr Card told how she was trying to manage 191 ED patients on her own, and that she and ED nurses were "overwhelmed" on the night Aoife presented at the hospital.
She said "every inch of the floor space" was taken up by patients on trollies when Aoife presented at the hospital.
“It was like a war-zone. It was an impossible situation,” she added.
The inquest was told life-saving medication which was available was not administered until it was too late.
HSE CEO Bernard Gloster said in a statement he wanted to restate the body's unequivocal apology to her family - saying no words will take away their pain.
'It's not going to change anything'
The inquest also heard from Aoife's mother Carol who said she had to watch her daughter die, despite begging for help from hospital staff.
Her parents said they welcome the verdict and apologies "but it's not going to change anything".
"We went there to get help and we didn't receive it," he father James said after the outcome.
"We arrived on the 17th and we never thought on the 19th we'd be leaving without Aoife," her mother Carol said.
"Aoife had, in my words, a horrible death - she suffered the whole night and I think people need to know that," she added.
'I never got to say goodbye'
Her sister Meagan said she never got to say goodbye.
"I'll never, ever forget Aoife she was just the most amazing sister ever," she said.
"It kills me all the time [that] I never got to say goodbye to her.
"When I got that call Aoife was already gone - I'll never forget that drive into the ICU.
"I never got to say goodbye to my little sister, I never got to say goodbye to her - she was gone," she added.
Meagan described her sister as "a beautiful girl inside and out".
