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A coroner has expressed concern that pharmacists are not permitted to provide differing strengths of the same medicines without an amended prescription, following the death of two-year-old Ava Grace Hodgkinson.
In the ‘Prevention of future deaths’ (PFD) report, published on 10 January 2025, Christopher Long, area coroner for Lancashire and Blackburn with Darwen, highlights the problem of restrictions that prevent pharmacists from issuing any alternate strengths of medicines, even when the medicine can be provided to enable the same dose to be administered.
He warned in the PFD, which was issued to the Department of Health and Social Care (DHSC), that there was a risk that “future deaths could occur unless action is taken”.
The PFD detailed how, following a short illness, Hodgkinson was examined by a GP. No infection was found but antibiotics were prescribed, and the following morning, she took the first dose. However, her condition later worsened, and she was taken to Ormskirk District General Hospital in Lancashire in the early afternoon.
On arrival, she was noted to be in cardiac arrest, and despite attempts to resuscitate, she died on 14 December 2022.
In evidence at the inquest, the report said her GP had prescribed amoxicillin with a dose of 250mg/5ml, which the pharmacy did not have in stock. The pharmacy had amoxicillin 125mg/5ml but could not issue this owing to the restrictions. According to the report, these restrictions led to a delay in the toddler receiving antibiotics.
“Ava’s parents could have been instructed to provide 10ml enabling the same dose of antibiotics to be provided,” the PFD said. The inquest concluded that Hodgkinson died of overwhelming sepsis caused by Streptococcus A infection.
The PFD said that evidence from the DHSC 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”.
The report continued: “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.”
PFD reports are legally required from a coroner when they believe action should be taken by a person, organisation, local authority or government department or agency to prevent future deaths. The DHSC must respond to the report by 10 March 2025, giving details on action taken or proposed to prevent future deaths, setting out the timetable for action or an explanation of why no action is proposed.
A spokesperson for the DHSC said: “Our deepest sympathies are with Ava’s family and loved ones in this tragic case. We are committed to learning lessons to prevent tragedies like this in the future and will consider the coroner’s report closely.”
The DHSC is understood to be considering enabling pharmacists to substitute to a different dose or formulation, under specified circumstances, where such a substitution might be both urgent and safe.
Commenting on the coroner’s report, Claire Anderson, president of the Royal Pharmaceutical Society (RPS), said: “This tragic case highlights the urgent need to remove barriers preventing pharmacists from supplying alternative strengths of the same medicine when necessary.
“We have long called for legislative change to allow pharmacists to make minor amendments to prescriptions during shortages. Current restrictions cause unnecessary delays, and the UK government must urgently update these rules to prioritise patient safety.”
“Pharmacists work tirelessly to manage shortages and ensure patients receive the medicines they need, but they must be empowered to act in the best interests of patient care. We will continue to work with policymakers and the wider healthcare system to ensure patient safety comes first,” she added.
The RPS has previously called for all community pharmacists to be allowed to make changes to prescriptions to “reduce unnecessary delays in providing medicines to patients in the event of a supply shortage”.
The Society repeated these calls in 2024 to allow community pharmacists to make “minor amendments to prescriptions to adjust the strength or formulation required” — changes hospital pharmacists have been able to make “for years”.
Kamila Hawthorne, chair of the Royal College of General Practitioners, has also previously said that community pharmacists should be able to dispense alternative formulations of antibiotics, or substitute them, if the prescribed form is unavailable, in the face of supply issues.
4 comments
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In Scotland this is done routinely either using the unscheduled care pathway or amending and annotating the original GP prescription. This allows timely supply of such medication.
Why is this even being discussed? If it did not relate to such a tragedy - so easily preventable in this case - it would be laughable. Surely the parents could have been counselled and the preparation labelled appropriately.
The patient wanted a dose of 250mg in 5ml, there was no 250mg . In my day I would have supplied the dose in 125mg units and counselled the patient as to the situation. Result- the patient would have lived and we would not be having this discussion. Any pharmacist who would not have done the same is being disingenuous. If we don’t exercise common sense we risk being labelled as “jobs worth” with possible fatal consequences, as in this case.
"Such a tragic story, and your coverage of the coroner’s concerns is both thoughtful and important. It’s unsettling to think about the implications of pharmacists not having the ability to amend prescriptions, especially in cases like this. Hopefully, this raises awareness and leads to necessary changes in the system. Thanks for highlighting this issue."