The government was warned of low stocks of a commonly-prescribed antibiotic nine days before a toddler died from a deadly infection.
Two-year-old Ava Hodgkinson succumbed to sepsis on December 14 in 2022. The toddler had been taken to her GP at Beacon Primary Care in Ormskirk the day before with a chesty cough at a time when there were national concerns about the increased prevalence of Group A Streptococcus, known as Strep A.
Ava’s GP had prescribed a liquid form of 250mg amoxicillin, due to being aware that first-line antibiotic phenoxymethylpenicillin – the recommended antibiotic for Strep A – was unavailable. But Banks Pharmacy was out of stock of the prescribed dose when Ava’s dad Adam went to collect it on December 13.
A new prescription for Ava was dispensed the following morning on December 14 but, just a few hours later, her condition deteriorated and she was rushed to A&E by her mum Jade. Ava then suddenly went into cardiac arrest and died a short time later.
Although the NHS was aware of low stock levels relating to phenoxymethylpenicillin used to treat Strep A on December 5 nothing was put in place to allow pharmacists to automatically prescribe an alternative or to combine lower doses – until after Ava died.
An inquest into Ava’s death today heard that the Department for Health and Social Care issued a Serious Shortage Protocol (SSP) for phenoxymethylpenicillin, which would have allowed pharmacists to use their own judgement to prescribe alternatives without waiting for a new prescription from a GP, on December 15 – the day after Ava died. An SSP for amoxicillin wasn’t issued until a later date.
Ava had been prescribed amoxicillin which the DHSC believed was of a “healthier” stock level than phenoxymethylpenicillin. However, it was out of stock in the dosage prescribed to Ava, and the pharmacist was not legally permitted to dispense an alternative.
Gila Sacks, the DHSC’s medicines director, explained that the government was repeatedly warned of the low stock levels of phenoxymethylpenicillin on December 5 – nine days before Ava died. But she defended the speed at which the SSP was issued at a time when the NHS was still struggling to cope with the Covid pandemic.
Ms Sacks explained that it is better for GPs to prescribe a medication, even if they know it is out of stock or low, so that the DHSC is aware of the demand and can therefore take steps to increase supply.
“The speed at which this was happening was very quick,” she said. “You can’t issue an SSP until you know what the alternatives are. You don’t want to do anything that will make anything worse.
“It was a very unusual situation, because of the Covid context, and these are drugs with a huge range of uses, so managing these types of drugs is quite unusual and meant that the clinicians involved had to be as careful as they could be before taking steps.
“So the gap between becoming aware of the issue on the December 7, and issuing the supply issue notification on December 12, and issuing the SSP on December 15 is far, far quicker than we would ever usually be able to do.”
Ava Hodgkinson was two when she died
Area Coroner Chris Long asked: “In your view was there any delay in issuing the SSP?”
“No,” Ms Sacks replied. “Given the highly uncertain and unprecedented context in how the infection was emerging, the complexity in doing this and the risk of getting it wrong, from what I have seen and heard about this period of time everyone did the quickest and safest things we could do in what were extremely difficult circumstances for the NHS.”
The inquest also heard from several pharmacy representatives including the branch which issued Ava’s prescription. They said that “the SSP coming in sooner would have helped a lot more patients” as they had struggled to source supplies for a week beforehand.
Referring to guidance issued ahead of the SSP, the pharmacist at Banks said: “It says on a national level sufficient stock exists but all I can say is I didn’t feel that there was sufficient stock at the time and that caused us to have a lot of difficulties and meant patients had to travel a lot further afield to get prescriptions.”
Jurors have heard that in one doctor’s opinion, had Ava started her course of antibiotics a day earlier, she more than likely would have lived for longer.
Dr Sharryn Gardner a paediatrician from Ormskirk and District General Hospital, was asked if, on the balance of probabilities, it is more likely than not that Ava would not have died or would have lived for longer had she been started on antibiotics “as originally planned”.
“It is more likely she would have lived for longer,” Dr Gardner said.
Dr Madhur Vardhan, a consultant microbiologist, was asked if the delay in Ava starting antibiotics, from December 13 to December 14, make a more than minimally, trivial or negligible contribution to Ava’s death.
“You would have to define when the sepsis set in,” Dr Vardhan replied. “I am not sure if giving the antibiotics on the 13th would have made a difference.”
The inquest, which is due to conclude on Thursday January 9, continues.
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