Jurors at the inquest of a two-year-old girl have heard that she died a day after a GP deemed there was “no sense of urgency” in prescribing antibiotics.
Adam Hodgkinson took his youngest daughter Ava to see a GP at Beacon Primary Care in Ormskirk around midday on December 13, 2022. Despite being aware of the heightened presence of Group A Streptococcus, also known as Strep A, the GP requested a specialist nurse practitioner to write a prescription at 1pm; however, it wasn’t completed until 2.04pm.
The pharmacy later found they lacked the necessary dose of amoxicillin and reached out to the surgery at 4.51pm to request an alternative prescription, which wasn’t issued until the next morning. Ava took her first dose of the antibiotics at 9.30am on December 14 but hours later her mum Jade rushed her to Ormskirk and District General Hospital where Ava collapsed and tragically died from “overwhelming sepsis”.
A jury inquest which started today (Monday January 6) at County Hall in Preston heard that there was a nationwide shortage of amoxicillin at the time due to the increased demand caused by a spike in the number of cases of Strep A.
Dr Rosalind Bonsor, GP partner at Beacon Primary Care, said that the need to start Ava on antibiotics “wasn’t felt to be urgent” despite Strep A being particularly prevalent at the time, reports Lancs Live.
“Many, many people were presenting worried about Strep A,” Dr Bonsor said. “The walk-in centre had had an extremely busy weekend and people were concerned because it was in the news. People were worried on the background of the national news and they were bringing children in due to their concern. They were presenting in large numbers because of their worries about any kind of upper respiratory tract issues.
“They had heard that this dangerous thing was about nationally. I don’t think the increased numbers reflected the increased prevalence – it reflected the increased concern.”
The GP added: “It wasn’t felt to be urgent with Ava. I can see why it ended up being urgent the following morning. There was no sense of urgency.”
The inquest heard that medications being out of stock “is a very common occurrence”. Among several changes introduced at Beacon Primary Care following Ava’s death staff across the surgery are now regularly informed about any medications that are not available.
Area Coroner Chris Long said: “Evidence from the parents indicated that when they first attended the pharmacy the prescription wasn’t ready. Mrs Hodgkinson returned to find that the amoxicillin was out of stock.”
Dr Bonsor said that, as a result of what happened to Ava, the surgery had “amended policies so that antibiotic prescriptions for a child are completed the same day”. “We don’t want this to ever happen again,” she added. “We don’t want to be in a situation again where we are questioned over whether that day might have made a difference,” the GP said.
The inquest then heard from Dr Sharryn Gardner from Ormskirk and District General Hospital. Recalling Ava’s collapse in A&E, after being taken there by her mum on December 14. Dr Gardner said: “It was clear straightaway that she was in cardiac arrest”.
The doctor agreed with the coroner that the direct cause of Ava’s death was “overwhelming sepsis”. She said that this was likely caused by Group A Streptococcus infection despite the bacteria not being found in the sample taken from Ava.
“Ava’s siblings both had it and a lot of people can carry it and be asymptomatic and then suddenly it becomes invasive and they develop sepsis,” Dr Gardner said, when she was asked to explain why she concluded that Ava had Strep A.
Dr Gardner was then asked if it would have made a difference if Ava had started on antibiotics sooner. “You can never know and I don’t think you can say,” she replied. You don’t know when it is suddenly going to become sepsis. What you see on the outside doesn’t necessarily match what is going on on the inside.”
The coroner repeatedly pressed Dr Gardner to say if, on the balance of probabilities, it is more likely than not that Ava would not have died or would have lived longer had she been started on antibiotics “as originally planned”.
“It is more likely she would have lived for longer,” Dr Gardner said.
The inquest, which is due to last four days, continues.
For breaking news in your area direct to your inbox every day, go here to sign up to our free newsletter
Teesside Live is now on WhatsApp and we want you to join our community.
Through the app, we’ll send you the latest breaking news, top stories, exclusives and much more straight to your phone.
To join our community group, you need to already have WhatsApp. All you need to do is click this link and select ‘Join Community’.
No one will be able to see who is signed up and no one can send messages except the Teesside Live team.
We also treat our community members to special offers, promotions, and adverts from us and our partners. If you don’t like our community, you can check out any time you like.
To leave our community click on the name at the top of your screen and choose ‘Exit group’.
If you’re curious, you can read our Privacy Notice.
Click here to join our WhatsApp community.