Ava Hodgkinson: Prevention of Future Deaths Report

Alcohol, drug and medication related deathsChild Death (from 2015)

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Date of report: 10/01/2025 

Ref: 2025-0016 

Deceased name: Ava Hodgkinson 

Coroners name: Christopher Long 

Coroners Area: Lancashire and Blackburn with Darwen 

Category: Child Death (from 2015) | Alcohol, drug and medication related deaths 

This report is being sent to: Department of Health and Social Care

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. [REDACTED], Secretary of State for Health and Social Care
1CORONER

I am Mr Christopher Long area coroner, for the coroner area of Lancashire and Blackburn with Darwen
2CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3INVESTIGATION and INQUEST

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..
4CIRCUMSTANCES OF THE DEATH

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.
5CORONER’S CONCERNS

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.
6ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 March 2025. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
8COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr & Mrs Hodgkinson (Ava’s parents), the Department of Health and Socoial Care and to the Lancashire’s Safeguarding Board

I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9DATE 10 January 2025
SIGNED BY CORONER