A coroner is writing to the Health Secretary urging him to boost pharmacists’ prescription powers after a two-year-old girl’s sepsis death.
Ava Hodgkinson succumbed to the lethal infection a day after a GP said treating her with antibiotics ‘was not felt to be urgent’.
The toddler’s father Adam took her to see a GP on December 13, 2022, who asked a specialist nurse practitioner to issue a prescription at 1pm – which did not happen for over an hour, an inquest heard.
A pharmacy then did not have the requested dose of amoxicillin in stock following a spike in Group A Streptococcus (Strep A) cases.
Staff contacted the Beacon Primary Care surgery in Ormskirk, Lancashire, to ask a doctor to prescribe an alternative, but the replacement prescription was not issued until the following morning.
Concluding an inquest into Ava’s death on Wednesday, coroner Chris Long said he would write to Health Secretary Wes Streeting calling for pharmacists to be allowed to give medication in a ‘different denomination’ during shortages.
He said there was a ‘risk’ of future deaths unless such a change takes place.Under current rules, pharmacists are only allowed to prescribe alternative medication if the Department of Health has issued a Serious Shortage Protocol notice.
After jurors in the inquest, held in Preston, found Ava died of natural causes, Mr Long called on the government to provide details of how legislation could be changed to allow pharmacists to prescribe medications in ‘different denominations’.
Ava  Hodgkinson was just two when she succumbed to sepsis caused by Group A Streptococcus in FebruaryÂ
The toddler, from Banks near Southport, collapsed in hospital and tragically died from ‘overwhelming sepsis ‘ that was ‘likely’ caused by Strep A
A coroner is writing to the Health Secretary urging him to boost pharmacists’ prescription powers after a two-year-old girl’s sepsis death
He said he would be writing a Prevention of Future Deaths report to Mr Streeting – adding: ‘At this stage, there is a risk (of future deaths) because pharmacists may well be able to issue medication in a different denomination or quantity.’
Mr Long said that ‘without understanding’ how a change allowing pharmacists to issue alternative medication in case of shortage ‘will be implemented’, the ‘risk remains’.
The inquest heard Ava took her first dose of antibiotics at 9.30am on December 14 – over 20 hours after they were recommended.
But hours later, her mother Jade rushed her to Ormskirk District General Hospital at lunchtime, where Ava collapsed and died.
GP partner Dr Rosalind Bonsor said the need to start Ava on antibiotics ‘wasn’t felt to be urgent’ despite Strep A being prevalent at the time.
But the GP added: ‘I can see why it ended up being urgent the following morning.’
The inquest heard medication types being out of stock ‘is a very common occurrence’.
It comes after the Mail’s End the Sepsis Scandal campaign, launched in 2016, led to the publication of NHS quality standards for diagnosis and care, including that possible sepsis should be treated by a senior doctor within an hour.
Ormskirk and District General Hospital in Lancashire where Ava tragically died in 2022
In hospitals, patients should be assessed, given antibiotics and put on intravenous fluids within 60 minutes of presenting.
Among several changes introduced at Beacon Primary Care after Ava’s death is staff being regularly informed about unavailable medications – and child antibiotic prescriptions being completed the same day.
‘We don’t want this to ever happen again,’ Dr Bonsor added.Dr Sharryn Gardner told the hearing that, when Ava arrived at A&E, it was ‘clear straightaway’ she was in cardiac arrest – with Strep A as the likely cause of sepsis.
Asked by coroner Chris Long if Ava starting a course of antibiotics on December 13 would have made a difference, she said: ‘It is more likely she would have lived for longer.’
