Ava Hodgkinson

I am Mr Christopher Long area coroner, for the coroner area of Lancashire and Blackburn with Darwen

On 21 August 2023 I commenced an investigation into the death of Ava Grace Hodgkinson, age 2. The investigation concluded at the end of the inquest on 8 January 2025. The conclusion of the inquest was that Ava died from natural causes due to overwhelming sepsis caused by Streptococcus A infection..

Ava Grace HODGKINSON died on 14 December 2022, at Ormskirk District General Hospital, Ormskirk in Lancashire. Following a short illness Ava was examined by a G.P. where no infection was found, but antibiotics were prescribed. The following morning, Ava took the first dose of antibiotics, however her condition later worsened and she was driven to Ormskirk District General Hospital in the early afternoon, where, upon arrival, she was noted to be in cardiac arrest and despite attempts to resuscitate, she did not recover. Miss HODGKINSON died of overwhelming Sepsis, resulting from Group A Streptococcus infection.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) In evidence at the inquest it was explained that the Ava had seen her GP who had prescribed amoxicillin with a dose of 250mg/5ml. The pharmacy did not have this strength in stock but did have amoxicillin 125mg/5ml in stock but could not issue this 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 (here Ava’s parents could have been instructed to provide 10ml enabling the same dose of antibiotics to be provided). This led to a delay in Ava receiving antibiotics. 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.