Summer Mant

I am Rachel Knight H M Coroner , for the coroner area of South Wales Central.

On 26 th February 2026, I concluded an inquest into the death of SUMMER RAE MANT. I reached a narrative conclusion as follows: Summer Rae Mant was born with MIRAGE syndrome which amongst other things, impacted her ability to fight infections. She developed a severe infection and virus and whilst an inpatient at Prince Charles Hospital Merthyr Tydfil on 17 th March 2024, reached the ceiling of ward-based care. During an attempt to switch between high flow nasal oxygen and the CPAP machine on 18 th March, there was a rapid desaturation which led to a period of hypoxia and a cardiac arrest. Following this, there was a further arrest during intubation, with another period of hypoxia of up to 8 minutes duration. These events of 17 th and 18 th March likely led to an irreversible hypoxic brain injury. Summer was transferred to PICU in Bristol and subsequently Cardiff, but never made any meaningful recovery. Aged 4, she developed a sudden multi-organ failure in mid-September 2024, with an uncertain cause. Sadly, her condition worsened, and a decision was made to provide palliative care and she died at Ty Hafan on 21 st September 2024. Although there were missed opportunities and sub-optimal care around the time of the acute desaturation on 17 th and 18 th March 2024, it was impossible to ascertain the precise contribution of the various factors, in the context of Summer’s MIRAGE syndrome and compromised immune system. The development of the multi-organ failure which directly led to death was likely multi- factorial in nature. Her cause of death was: 1a  Unexplained multi-organ failure in a 4 year old child with MIRAGE syndrome, following a prolonged inpatient stay due to an acquired brain injury from March 2024 following a period of hypoxia whilst being treated for parainfluenza virus and a superadded chest infection.

The Inquest focused upon: a. The events of 17 th and 18 th March; and b. Summer’s cause of death

During the course of the inquest the evidence revealed matters giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is  my statutory duty to report to you. The MATTERS OF CONCERN are as follows. During the resuscitation of Summer at Prince Charles Hospital in theatre following intubation, there was a delay in obtaining adrenaline. The incident occurred at night and it involved a skeleton  staff including some junior doctors, fairly new to the hospital. The delay in finding adrenaline, was likely due to the fact that there is no standardised crash  trolley, and junior doctors frequently rotate between hospitals and health boards and encounter  different set-ups. Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every  hospital setting in which junior doctors rotate, to minimise confusion at a time critical moment.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.