A two-year-old died of “overwhelming sepsis, resulting from Group A Streptococcus (strep A) infection” after a “delay” in receiving antibiotics due to restrictions preventing a pharmacist from amending an out-of-stock prescription, a coroner’s report has revealed.
Ava Hodgkinson was seen by a GP following a short illness in December 2022 and although “no infection was found”, she was prescribed antibiotics, Lancashire and Blackburn coroner Christopher Long said.
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The GP prescribed an amoxicillin dose of 250mg/5ml but it was not in stock at the pharmacy, meaning she needed an amended prescription, according to the report published this week (January 13).
Ava took the first dose of antibiotics the following morning but “her condition later worsened”, it said.
She was taken to Ormskirk District General Hospital in the early afternoon, where she was found to be in cardiac arrest and “despite attempts to resuscitate, she did not recover” and died on December 14, it added.
“Complex” issue
The inquest found that although the pharmacy did not have amoxicillin 250mg/5ml available, it did have amoxicillin 125mg/5ml in stock.
But the pharmacy could not issue this alternative dose “as restrictions currently in place prevent a pharmacist issuing any different strength of medication without an amended prescription, even where the medication can be provided to enable the same dose to be administered”.
Long said that “this led to a delay in [her] receiving antibiotics”, adding that Hodgkinson’s parents “could have been instructed to provide 10ml enabling the same dose of antibiotics to be provided”.
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DH evidence at the inquest included that “this issue was being actively considered” but was “complex” and “any change was likely to need public consultation and ministerial support”.
It added that “it was not possible to provide any timeframe for any appropriate steps to be taken to consider changing the restrictions preventing pharmacists from issuing medication where they can provide the same dosage of the same medication in a different denomination”.
“Deepest sympathies”
Long sent the report to the health secretary who has until March 10 to respond, saying that “there is a risk that future deaths could occur unless action is taken” and that the DH has “the power to take such action”.
But the DH stressed that the coroner did not find that anything relating to the provision of antibiotics contributed to the death and that there were no system failings on the part of the state.
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A DH spokesperson expressed its “deepest sympathies” with Hodgkinson’s family and loved ones in this “tragic case”.
They said that the DH began receiving enquiries on strep A on December 5 2022 and began assessing the antibiotics available from that date onwards.
“We are committed to learning lessons to prevent tragedies like this in the future and will consider the coroner’s report closely,” they told C+D yesterday (January 14).
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The DH also told C+D that it is currently considering enabling pharmacists to substitute to a different dose or formulation under specified circumstances where this might be both urgent and safe, with further details to be set out in due course.
It added that it has a range of well-established processes to make sure that where there are shortages, alternative treatments are available to patients until their usual treatments are back in stock.
Beacon Primary Care, where Hodgkinson was seen by a GP, said the practice offers “sincere condolences” and has introduced “several changes…as a direct result of what happened”.
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“Going forward, should there be problems with antibiotic supply, the practice has a policy of changing prescriptions for children on the same day if the antibiotic can’t be found locally,” lead GP Dr Rosalind Bonsor told C+D.
Patients can now also be “triaged directly by a clinician, so the most appropriate service and appointment is recommended”, she added.
Strep A 2022 timeline
Strep A and increasing shortages of antibiotics dominated headlines in December 2022 when Hodgkinson died.
On December 5, the Independent Pharmacies Association (IPA) said that pharmacies across the country were struggling to get hold of amoxicillin as the UK faced mounting cases of strep A infections.
C+D reported on December 12 that wholesalers had put the blame of soaring antibiotic prices at manufacturers' doors, following pharmacists' complaints that they had been left out of pocket amid growing concerns over strep A.
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By December 14, the DH restricted wholesalers from exporting or hoarding some antibiotics used to treat strep A - including amoxicillin and phenoxymethylpenicillin - as pharmacists faced mounting demands for the drugs.
The following day, a C+D exclusive reported that pharmacists raised concerns about throngs of distressed parents calling up “in a frenzy” looking for antibiotics to treat strep A, as well as having to pay “outrageous” prices for drugs.
And on December 16, pharmacy leaders said pharmacists should urgently be given powers to make changes to prescriptions without the need for SSPs – after the DH issued SSPs for three penicillin medicines.
