A tragic case has led to calls for urgent reforms in prescription practices, following the death of two-year-old Ava Hodgkinson, who succumbed to sepsis after a delayed prescription for antibiotics.
The Incident and Delayed Prescription
On December 13, 2022, Ava’s father, Adam, took her to a GP when she was showing signs of illness.
After consulting with a specialist nurse practitioner, the GP recommended antibiotics but did not prioritize the prescription, deeming it “not urgent.”
However, it wasn’t until more than an hour later that the prescription was sent to the pharmacy, and the requested dose of amoxicillin was unavailable due to a surge in cases of Group A Streptococcus (Strep A).
As a result, the pharmacy contacted Beacon Primary Care surgery in Ormskirk, Lancashire, to request an alternative prescription.
Unfortunately, the replacement medication wasn’t issued until the following morning, by which point Ava’s condition had worsened significantly.
Coroner’s Concerns and Call for Action
Following the inquest into Ava’s death, coroner Chris Long expressed concerns about the risks of similar incidents happening in the future.
He plans to write to Health Secretary Wes Streeting, urging for changes to allow pharmacists more flexibility in issuing prescriptions, particularly during medication shortages.
Long emphasized the importance of giving pharmacists the authority to prescribe alternative medications in different quantities to avoid delays that could prove fatal.
Current Limitations and the Need for Reform
Under current regulations, pharmacists can only prescribe alternative medications if there’s an official Serious Shortage Protocol notice from the Department of Health.
Long warned that without proper changes to legislation, there is a “risk” of future deaths caused by delays in treatment.
In this case, Ava didn’t receive her antibiotics until 9:30 a.m. on December 14, over 20 hours after the medication was initially recommended.
Tragically, by the time Ava was rushed to the hospital later that day, her condition had deteriorated, and she passed away from sepsis, a condition caused by the Strep A infection.
Improved Practices and Campaigns After Ava’s Death
This heart-wrenching incident has spurred changes in the Beacon Primary Care surgery, with staff now being kept informed about medication shortages, and a new protocol ensuring child antibiotic prescriptions are filled the same day.
These changes aim to prevent similar delays from happening in the future.
Dr. Rosalind Bonsor, a GP partner at Beacon Primary Care, expressed regret over the situation, acknowledging that, although the antibiotics were not deemed urgent initially, the situation worsened overnight, leading to the tragic outcome.
Dr. Sharryn Gardner, who treated Ava at the hospital, confirmed that by the time Ava arrived, she was already in cardiac arrest due to sepsis.
The Bigger Picture and the End the Sepsis Scandal Campaign
Ava’s death has brought renewed focus on the need for swift and accurate diagnosis and treatment of sepsis.
This follows the Mail’s End the Sepsis Scandal campaign, launched in 2016, which advocated for quicker action when sepsis is suspected, including a requirement for treatment to begin within an hour of diagnosis.
The NHS now has quality standards in place for the diagnosis and treatment of sepsis, and hospitals are expected to treat patients within 60 minutes of presentation.
These guidelines highlight the importance of timely intervention in cases like Ava’s, where quick administration of antibiotics could have saved her life.
Conclusion: A Tragic Lesson and the Road to Change
Ava’s tragic passing has highlighted critical gaps in how prescription delays can contribute to worsening health outcomes.
The coroner’s call for changes in how pharmacists are able to respond to medication shortages is just one step toward ensuring that no other family has to face the heartbreak of losing a loved one to something as preventable as sepsis.
The medical community and policymakers now face the challenge of making the necessary changes to protect future lives.