Coroner concerned over GP surgery's 'missed opportunity' in tragic death of 22-month-old toddler

Hailey Thompson died with Strep A

A coroner has written to a GP surgery to raise urgent concerns about the way it handled the case of a 22-month-old toddler who later died with Strep A.

Manchester West area coroner Michael Pemberton said there is a 'risk that future deaths could occur unless action is taken'. Hailey Thompson's death in December 2022 was caused by sepsis and pneumonia which was caused by Group A streptococcus, a bacterial infection otherwise known as Strep A.

Hailey was a patient at Ashton Medical Practice in Ashton-in-Makerfield.

SSP Health, the group which runs the practice, said it would review the report's findings, but added the concerns raised by the coroner 'relate to common practices which are in place across the vast majority of doctors surgeries in the country'.

Earlier this month an inquest jury concluded the Wigan toddler died of natural causes. The jurors also said there had been 'missed opportunities' for the case to be reviewed 'at primary care level', although these 'did not contribute' to her death.

In a prevention of future deaths report, Mr Pemberton has raised concerns about how Ashton Medical Practice dealt with a request for an appointment from Hailey's mother Ibolya Adam. It came after the toddler suffered an apparent allergic reaction to antibiotics she was taking for a suspected throat infection in the days before her death. The antibiotics were stopped three days in after Hailey developed a rash.

Mr Pemberton wrote that Ms Adam initially spoke to an administrative member of staff described as a 'care navigator', at a call centre. This was to get 'advice or support' following the allergic reaction. They referred the appointment to a pharmacist who 'was not competent to deal with a paediatric medication enquiry'.

The pharmacist sent a message back saying they were not able to handle the appointment, but not on the medical records system where an 'auditable trail would exist'. Mr Pemberton also raised concerns that the care navigator did not have a 'clear pathway... or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock'.

Mr Pemberton wrote: "These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case.

"The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances."

Hailey, who was described by her parents as a 'very funny and very happy' little girl who loved muddy puddles and dressing up, was found unresponsive in her cot on December 19, 2022. She was taken to Royal Albert Edward Infirmary in Wigan where she died around two hours later.

The inquest heard the toddler had been taken to the same hospital the day before her death after she was 'panting for breath'. After a four wait in A&E she was diagnosed with a viral infection and sent home. An expert told the inquest at Bolton coroner's court that this decision had been 'reasonable'.

After the inquest, Hailey's parents said while they accept the jury's conclusion they 'remain concerned about the quality of care Hailey received in the days leading up to her death'.

Andy Scaife, CEO of SSP Health, said: "We are deeply saddened at the death of one of our patients. Our thoughts and heartfelt condolences are with Hailey’s family and loved ones during this difficult time.

"We have received the Regulation 28 Report from the coroner but cannot comment, in detail, at this time as we are still reviewing the report findings. We note that the concerns raised by the coroner relate to common practices which are in place across the vast majority of doctors surgeries in the country and are not specific to the surgery in this case.

"We also note that the coroner specifically states that the concerns raised did not contribute to this very sad death. As is appropriate, we are currently conducting a thorough internal review to understand the exact circumstance, which will include a review of the factual accuracy of certain aspects of the report and the appropriateness of a Regulation 28 Report being raised in this case. Once completed, our response will be shared with the coroner."