A two-year-old girl died from Strep A-related sepsis after delays in receiving medicine when the pharmacy her parents visited was unable to supply a different strength of amoxicillin to the one prescribed by her GP, a coroner has found. 

In a Prevention of Future Deaths report published yesterday (January 13), Lancashire coroner Christopher Long said an inquest had found that Ava Grace Hodgkinson of Ormskirk died on December 14, 2022 “from natural causes due to overwhelming sepsis caused by Streptococcus A infection”. 

The inquest heard that after a brief period of illness Ava was seen by her GP who did not find any infection but prescribed antibiotics. 

However, when her parents went to a local pharmacy the pharmacist did not have the prescribed 250mg/5ml formulation of amoxicillin, and regulatory restrictions meant they were unable to supply 125mg/5ml which they had in stock. 

“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,” said Mr Long. 

He added: “Ava’s parents could have been instructed to provide 10ml enabling the same dose of antibiotics to be provided.” 

Following these delays, Ava received her first dose of antibiotics the next morning, but when her condition worsened she was brought to Ormskirk General Hospital in the early afternoon, where upon arrival she was found to be in cardiac arrest. Attempts to resuscitate her were unsuccessful. 

Representatives from the Department of Health and Social Care told the inquest that the question of whether pharmacists should be allowed to use their judgment to dispense a different strength of a prescribed medicine is “being actively considered”.

However, DHSC officials said the issue “was complex and any change was likely to need public consultation and ministerial support”.

They were unable to offer a timeframe for when a decision might be made on the issue. 

The coroner’s report was addressed to health secretary Wes Streeting, who is obliged to respond by March 10 and confirm whether Labour plans to revisit the current regulations that prevent pharmacists from supplying a prescribed medication in a different domination to that specified by the patient’s GP.