A coroner will write to Health Secretary Wes Streeting after low stocks of antibiotics resulted in delays treating a toddler who later died from a deadly infection.
Ava Hodgkinson was taken to see a GP at Beacon Primary Care surgery on December 13 in 2022. The two-year-old was suffering from a chesty cough and, due to a nationwide outbreak of Strep A, her parents were concerned she had caught the infection.
Locum GP Dr Rizwan asked a specialist nurse practitioner to prescribe liquid amoxicillin, an antibiotic, but the prescription wasn’t issued until an hour later. When Ava’s dad Adam went to the pharmacy in their home village of Banks, he was told the dose which had been prescribed was out of stock.
Although the government was aware of low stocks of antibiotics across the country, due to the increased prevalence of Strep A, the Department for Health and Social Care had not issued a Serious Shortage Protocol (SSP) which would have allowed the pharmacist to dispense the correct total dose in a different denomination.
Two days later, an SSP was issued but only for phenoxymethylpenicillin, which is considered the first-line antibiotic for Strep A. The GP had decided against prescribing phenoxymethylpenicillin for Ava as she was aware it was out of stock.
Due to the GP surgery’s “prescription line” not being open until 4pm, it wasn’t until 4.51pm that a different script was issued, but it wasn’t dispensed until the following morning on December 14.
Just a few hours after taking her first dose of antibiotics, Ava’s condition deteriorated, and her mum Jade put her in the car to take her to A&E at Ormskirk & District General Hospital.
However, on the way to the hospital, Jade suddenly became aware that Ava had stopped breathing. When she carried her little girl into A&E doctors discovered she was in cardiac arrest and she was pronounced dead shortly afterwards.
Ava Hodgkinson with her mum Jade
An inquest at Preston’s County Hall, which started on Monday January 6 and concluded today, heard that several changes have been introduced at Beacon Primary Care, and the pharmacy, as a direct result of what happened to Ava.
These include a new policy to ensure that antibiotics for children are dispensed on the same day they are prescribed and an improved triage system so that clinicians are involved in determining the urgency of an appointment request.
The inquest heard differing expert opinions regarding whether or not Ava would have lived for longer, or survived, had she received her first dose of antibiotics on December 13 instead of the following day.
Dr Sharryn Gardner, a paediatrician from Ormskirk and District General Hospital, said that “it is more likely she would have lived for longer” while Dr Madhur Vardhan, a consultant microbiologist, said it was impossible to say because it could not be determined when Ava developed the sepsis which caused her death.
Gila Sacks, the Department of Health and Social Care’s medicines director, told the jury that the government was “actively considering” changing legislation to allow pharmacists to prescribe a different denomination of medication, to make a prescription up to the total amount prescribed.
This would require a public consultation and ministerial support. Pharmacists are currently only able to dispense different doses if a Serious Shortage Protocol (SSP) has been issued by the government.
Ava Hodgkinson
Area Coroner Chris Long, who sat with a photograph of Ava in front of him throughout the proceedings, said that he would issue a Report to Prevent Future Deaths to Health Secretary Wes Streeting.
Although such reports do not allow a coroner to specify what action should be taken Mr Long said the Department of Health could provide details of how, and when, legislation can be changed to allow pharmacists to prescribe medications in different denominations.
“At this stage there is a risk because pharmacists may well be able to issue medication in a different denomination or quantity,” the coroner said.
“Without understanding how and when it will be implemented the risk remains. Where there is a risk that may impact on lives in the future and a coroner considers that action should be taken I am duty bound to issue a report.”
The jury returned a conclusion of natural causes and said: “Ava Grace Hodgkinson died on December 14, 2022, at Ormskirk & District General Hospital, Ormskirk, following a short illness.
“Ava was examined by a GP where no infection was found but antibiotics were prescribed. The following morning, Ava took the first dose of antibiotics, however her condition worsened and she was taken to Ormskirk & District General Hospital where, on arrival, she was found to be in cardiac arrest and did not recover.”
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