Coroner urges Government ease pharmacy restrictions following death of 2-year-old girl from sepsis
A coroner has warned the Government that more people could die if they don’t take action on restrictive pharmacy rules, following the death of a two-year-old girl.
Coroner Christopher Long has compiled a Report To Prevent Future Deaths, after handling the tragic case of Ava Grace Hodgkinson. Ava, from Banks, died of “overwhelming sepsis” caused by a Streptococcus A infection, on December 14 2022, at Ormskirk District General Hospital.
What happened?
An inquest found that Ava was originally taken to the GP in December 2022 with a chesty cough, with parents Adam and Jade leaving with a prescription for amoxicillin with a dose of 250mg/5ml.
When Mr Hodgkinson went to collect it from Banks Pharmacy, he was told they didn’t have this strength in stock, but did have amoxicillin 125mg/5ml. However, they couldn’t issue that 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. In this case, Ava's parents could have been instructed to provide 10ml enabling the same dose of antibiotics to be provided. This restriction led to a delay in Ava receiving antibiotics.
The following morning, a new prescription was available for collection, but only hours after taking her first dose, Ava’s condition deteriorated, leading her mother Jade to carry her into A&E at Ormskirk & District General Hospital. There the two-year-old went into cardiac arrest and died.
What does the coroner want?
Now Mr Long has used his powers to ask the Secretary of State for Health and Social Care - Wes Streeting - for changes to the restrictions on pharmacies. He says there is a risk that future deaths could occur unless action is taken.
In his report Mr Long states: “Evidence from the Department of Health and Social Care included that this issue was being actively considered but it was explained the issue was complex and any change was likely to need public consultation and ministerial support.
“It was also explained 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. In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.”
The Secretery of State has until March 10 to respond to the report with details of action taken or proposed to be taken, setting out the timetable for action. Otherwise they must explain why no action is proposed.