Clinical Negligence & Catastrophic Injury Solicitors
Coroner urges action after girl, 2, died after antibiotics delay
Action has been ordered by a coroner after the death of a two-year-old Lancashire girl, who died after the antibiotics she was prescribed were out of stock.
Ava Hodgkinson died from 'overwhelming sepsis 'that was 'likely' caused by Strep A, after collapsing in hospital in December 2022.
An inquest into her death heard that her farther, Adam Hodgkinson, took Ava, his youngest daughter to see a GP at Beacon Primary Care in Ormskirk, Lancashire, on December 13, 2022. At 1pm, a specialist nurse practitioner was asked to issue a prescription.
The prescription was not issued until 2.04pm and the pharmacy then discovered that it did not have the requested dose of amoxicillin in stock. They contacted the GP surgery at 4.51pm asking for an alternative prescription to be issued.
This was not done until the following morning and Ava took her first dose of antibiotics at 9.30am on December 14, more than 20 hours after first contacting the GP.
Shortly after, her mother Jade rushed her daughter to Ormskirk District General Hospital where Ava collapsed and died from “overwhelming sepsis”, probably caused by a strep A infection.
A GP partner at Beacon Primary Care, Dr Rosalind Bonsor, told a jury inquest that the need to start Ava on antibiotics “wasn’t felt to be urgent” despite strep A being particularly prevalent at the time.
The said: “Many, many people were worried about strep A. The walk-in centre had an extremely busy weekend and people were concerned because it was in the news. People were worried on the background of the national news and they were bringing children in due to their concern.”
Dr Bonsor added: “It wasn’t felt to be urgent with Ava. I can see why it ended up being urgent the following morning. There was no sense of urgency.”
The inquest heard that medication being out of stock “is a very common occurrence”, and there had been a nationwide amoxicillin shortage at the time.
Dr Bonsor said that, as a result of what happened to Ava, staff at Beacon Primary Care are now informed of any medication being out of stock and that the surgery had “amended policies so that antibiotic prescriptions for a child are completed the same day.”
A doctor at Ormskirk District General Hospital, Dr Sharryn Gardner, agreed with the coroner that the direct cause of Ava’s death was sepsis. While strep A bacteria was not found in the sample taken from Ava, both her siblings had it and Ava may have been “asymptomatic.”
Asked if it would have made a difference if Ava had started on antibiotics sooner, Dr Gardner said: “You can never know and I don’t think you can say. You don’t know when it is suddenly going to become sepsis. What you see on the outside doesn’t necessarily match what is going on on the inside.”
Pressed on the issue by area coroner for Lancashire and Blackburn with Darwen, Chris Long, Dr Gardner added: “It is more likely she would have lived for longer.”
In his Prevention of Future Deaths (PFD) report, Christopher Long, said that “there is a risk that future deaths could occur unless action is taken.”
The PFD report raised concerns about pharmacy restrictions currently in place that prevent a pharmacist from issuing any different strength of medication without an amended prescription.
Mr Long's report added: "In evidence at the inquest it was explained that Ava had seen her GP who had prescribed amoxicillin with a dose of 250mg/5ml. The pharmacy did not have this strength in stock but did have amoxicillin 125mg/5ml in stock but could not issue this."
Despite the pharmacy having a different suitable dose in stock, under the current legislation, it could not be dispensed without a new prescription.
Mr Long expressed concerns about this regulatory barrier, noting that there “is a risk that future deaths could occur unless action is taken.”
Ava’s parents, Jade and Adam, along with the Lancashire Safeguarding Board and the Chief Coroner, were notified of the report.
In a statement Jade and Adam said: “There are not enough words to express the magnitude of pain and devastation we feel as a family at the loss of our beautiful daughter, Ava Grace.
"Ava radiated beauty both inside and out – the purest of souls; gentle, kind and loving and whose love for nature, wildlife, and those around her shone through.
"Comfort is very difficult to come by, but we take some from the light that has been shone on Strep A, its potentially devastating consequences, and the need for urgent treatment to be available when a child needs it. Ava was let down by the shortage of antibiotics and this should never happen again to any other child.”
The coroner has formally recommended that the Department of Health and Social Care address the issue to prevent similar delays in the future.