An inquest is being held into the death of Ava Hodgkinson
An inquest is being held into the death of Ava Hodgkinson
A two-year-old girl “would have lived longer” had she been prescribed antibiotics sooner, jurors at an inquest have heard. Adam Hodgkinson took his youngest daughter Ava to see a GP at Beacon Primary Care in Ormskirk at lunchtime on December 13 in 2022.
The GP was aware of the increased prevalence of Group A Streptococcus – known as Strep A – and asked a specialist nurse practitioner to issue a prescription at 1pm but this wasn’t done until 2.04pm. The pharmacy then discovered they did not have the requested dose of amoxicillin in stock and contacted the GP surgery to ask a doctor to prescribe an alternative.
That call was made at 4.51pm but the new prescription wasn’t issued until the following morning. Ava took her first dose of the antibiotics at 9.30am on December 14 but hours later her mum Jade took her to Ormskirk and District General Hospital where Ava collapsed and died from “overwhelming sepsis”, reports LancsLive.
A jury inquest which started today, Monday January 6, at County Hall in Preston heard 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.
“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 added.
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 the direct cause of Ava’s death was “overwhelming sepsis”. She said 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. She replied: “You can never know and I don’t think you can say. 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”. Dr Gardner said: “It is more likely she would have lived for longer,” Dr Gardner said.
The inquest, which is due to last four days, continues tomorrow, Tuesday January 7.
