It was an everyday situation that rapidly became a nightmare no parent should have to face.
Two-year-old Ava Hodgkinson was under the weather and her dad, Adam, had taken her to the GP who suspected the toddler had a bacterial throat infection, Strep A. At the time, in December 2022, there was a particularly severe outbreak. GPs had been put on high alert and were instructed to prescribe children suspected to have the bug – which can be fatal – with the antibiotic amoxicillin as quickly as possible.
Ava’s GP wrote a prescription and told Adam, 33, to visit the practice’s pharmacy to pick up the medication.
Except there was a problem. The pharmacy did not have the 250mg dose of the prescribed amoxicillin syrup in stock.
That winter there was a national shortage of the medicine – in part due to the demand caused by the Strep A outbreak.
Two-year-old Ava Hodgkinson was under the weather and her dad, Adam, had taken her to the GP who suspected the toddler had a bacterial throat infection, Strep A . At the time, in December 2022, there was a particularly severe outbreak
The pharmacy did, however, have supplies of amoxicillin – in a smaller 125mg dose. Ava’s parents could have been instructed by the pharmacist to give her a double dose – but due to NHS regulations, this is illegal. Pharmacists can only fill prescriptions exactly as written by doctors. They cannot give patients a different strength of a drug nor can they offer another medicine – for example, a similar antibiotic.
When these all-too-common situations arise, the patient must go back to their GP for a new prescription. And in Ava’s case, this happened the next morning. But the delay had a catastrophic effect.
She was given her first dose at 9.30am, but within hours her condition had deteriorated.
Her mother Jade, 34, rushed her to hospital – but it was too late. Shortly after arriving, Ava suffered a fatal cardiac arrest.
The cause of death was sepsis – where the immune system overreacts to an infection, in this case Strep A, which severely damages the body’s organs.
Jade and Adam, from Ormskirk, Lancashire, say they are still struggling with the ‘magnitude of pain and devastation’ caused by the loss of Ava.
They describe her, in a statement through their lawyers, JMW Solicitors, as ‘gentle, kind and loving’, whose affection for ‘nature, wildlife and those around her shone through’.
During an inquest, Dr Sharryn Gardner, who worked at Ormskirk and District General Hospital where Ava died, admitted if medication had been given sooner it could have prolonged Ava’s life.
Ava’s parents, Jade and Adam, say they are still struggling with the ‘magnitude of pain and devastation’ caused by the loss of Ava (pictured)
Christopher Long, coroner for Lancashire and Blackburn, was clear in his conclusion – the delay in starting Ava’s treatment was ‘a matter of concern’.
Mr Long added that her parents ‘could have’ been instructed to provide double the lower dosage but were not allowed to without an ‘amended prescription’ from their doctor.
He noted that Department of Health and Social Care officials had provided evidence indicating ‘this issue was being actively considered’, but ‘the issue was complex and any change was likely to need public consultation and ministerial support’.
He warned that action needs to be taken to prevent future deaths.
The shocking case is the latest to come to light in a long-running prescription drug shortage that is engulfing the UK. Common prescription medicines, including HRT, statins and even asthma inhalers and epilepsy drugs, have been in short supply. An shocking half of patients have been affected by the shortages since 2022, according to research.
Amid mounting concern, last year The Mail on Sunday launched its campaign – End The Drug Shortage Nightmare.
The supply problems have largely been triggered by increased global demand and manufacturing issues, but industry insiders say there are simple steps that policymakers could take to improve the situation.
Among our four key demands, we are calling on the Government to give pharmacists the power to make substitutions for patients when drugs are out of stock.
The tragic case of Ava Hodgkinson shows just how vital it is that this change is made without delay.
Our campaign, backed by the Independent Pharmacies Association (IPA), also calls for the creation of a database which would allow patients to see which pharmacies have stock of their prescriptions – ending the need to trawl across towns and cities looking for them or being sent back to GPs for a new prescription.
Drug manufacturers ought also to be required to give advance warning of shortages in supply, and to face stiff fines if they fail to do so. And, finally, we believe patients should be permitted to use hospital pharmacies to source crucial drugs if they have them in stock – at present, only patients treated by a hospital trust can access its supplies.
Experts have long warned in this newspaper that solving the crisis is a matter of life and death. Health chiefs have failed to act despite nearly a dozen articles on the issue and we have been refused multiple requests to interview MP Stephen Kinnock, the minister responsible for community pharmacies.
And earlier this month the Government rejected calls from the Health and Social Care Committee to allow pharmacists to make prescription substitutions due to ‘patient safety’ concerns.
Currently, chemists can provide patients with alternative medicine only if the Government has issued a specific exemption for that drug – known as a serious shortage protocol.
But experts say the protocols are issued weeks or even months after the shortages have begun.
‘Pharmacists have been raising the issue of shortages for years, but our calls have repeatedly fallen on deaf ears,’ says Thorrun Govind, former chair of the Royal Pharmaceutical Society. ‘Allowing pharmacists to make substitutions is common sense. The serious shortage protocols are not fit for purpose and are akin to shutting the door after the horse has bolted.
‘Failure to address shortages will lead to further tragic cases.’
Earlier this month, a Leeds coroner blamed the death of an epilepsy patient on drug shortages.
David Crompton, 44, had been unable to get carbamazepine, also known as Tegretol, which helped control his seizures. On December 13 he had a fall as a result of a seizure – the second time it had happened – which led to a fatal heart attack.
And last week, a London coroner concluded that drug shortages were linked to the death of Brunel University student Charlie Marriage, 32, who had spent two days trying to find his vital epilepsy prescription medicine, perampanel. Xavier Mooyaart, assistant coroner for Inner South London, gave the cause of Charlie’s death, in June 2021, as sudden death in epilepsy and warned that there were a ‘clear cohort of patients’ who might be ‘similarly vulnerable in the future’.
A London coroner concluded that drug shortages were linked to the death of Brunel University student Charlie Marriage, 32, who had spent two days trying to find his vital epilepsy prescription medicine, perampanel
David Crompton, 44, had been unable to get carbamazepine, also known as Tegretol, which helped control his seizures. On December 13 he had a fall as a result of a seizure – the second time it had happened – which led to a fatal heart attack
Experts say that following these tragic cases, it is crucial the Government steps in before more patients come to harm.
A survey of pharmacists, carried out last year by The Pharmaceutical Journal, found that two out of three believe drug shortages have put their patients at risk.
Other medications which have been in near-constant short supply in the past few years include ADHD tablets – used by millions to manage the attention-deficit disorder – and a vital cystic fibrosis drug called Creon.
Patients with the degenerative genetic disease often lack the enzymes needed to absorb crucial fats and oils from food. Creon helps the body do this. It’s also given to many patients with pancreatic cancer as they can lose the ability to create these enzymes. Without the drug, they can lose a dangerous amount of weight.
But as The Mail on Sunday was first to report in August 2024, Creon has been in such short supply that patients have been asking friends and family living in other countries to purchase the drug for them and post it over.
Experts argue that the fact Creon has often been available outside the UK – including in nearby nations such as Spain and France – is proof that shortages can be preventable.
Hannah Jacobs, 13, fell ill after Costa Coffee staff accidentally used regular milk instead of soya. However an inquest found that her death could have been prevented if the nearby pharmacy, where Hannah and her mother Adimbola Duyile rushed, had the right anti-allergy injection in stock
Last year this newspaper also revealed a nationwide shortage of life-saving EpiPens was linked to the death of a schoolgirl with a severe dairy allergy who died after one sip of a hot chocolate.
In February 2023, Hannah Jacobs, 13, fell ill after Costa Coffee staff accidentally used regular milk instead of soya. However an inquest found that her death could have been prevented if the nearby pharmacy, where Hannah and her mother Adimbola Duyile rushed, had the right anti-allergy injection in stock.
The pharmacist told the coroner in September 2024 that the only EpiPen on the shelf contained 150mg of adrenaline – just a third of the necessary amount needed for a 13-year-old.
Santokh Kahlon, director of Daynight Pharmacy in Barking, Essex, said his staff had desperately searched for another dose but were unable to find one due to a UK-wide ‘lack of supply’.
‘What will it take for the Government to act on the issue of drug shortages?’ says Dr Leyla Hannbeck, chief executive of the IPA. ‘Patients are dying because of a lack of medicine. This is something that everyone should have a human right to, like food and water.
‘The Mail on Sunday launched its campaign to tackle this problem more than half a year ago, and pharmacists have been warning about the dangers for even longer. It is really sad it has come to this.
‘The Government must do something before more people are seriously harmed.’
A Department of Health and Social Care spokesman said: ‘Our deepest sympathies are with all those who lost loved ones – we are committed to learning lessons to prevent tragedies like this in the future. This Government inherited ongoing global supply problems impacting medicine availability, and a pharmacy system that has been neglected for too long. We are working closely with industry, the NHS, manufacturers and other partners to resolve supply issues as quickly as possible.’
