Hailey Anne Thompson · Prevention of Future Deaths report

On 17 January 2023 I commenced an investigation into the death of Hailey Anne Thompson aged 22 months. The investigation concluded at the end of the inquest held with a jury on 3 April 2025.
The conclusion of the inquest was natural causes, and the medical cause of death was 1a Sepsis, Pneumonia (Group a Streptococcus)

Hailey Anne Thompson attended her GP on 7th December 2022 and was prescribed antibiotics to treat bacterial tonsillitis. They were subsequently stopped after 3 days due to Hailey developing a rash, thought to be an allergic reaction. There was a missed opportunity for this to be reviewed at primary care level, however this did not contribute to her death.
Hailey remained unwell and was seen by her GP on 16th December 2022, and again on 18th December 2022 at the A&E department at the Royal Albert Edward Infirmary in Wigan. On both occasions a viral upper respiratory infection was diagnosed and therefore, antibiotics were not required. On the morning of 19th December 2022, Hailey was found unresponsive at home. She was transported to the Royal Albert Edward Infirmary in Wigan by ambulance. Efforts to resuscitate her were unsuccessful and she was declared deceased. The cause of death was sepsis, arising from Streptococcus A infection in the lungs causing Pneumonia.

1. During the course of evidence, an issue was explored regarding Hailey’s mother attempting to obtain an appointment or advice with the GP surgery following an apparent allergic reaction to prescribed antibiotics. These had been prescribed on 7 December for tonsillitis but stopped after three days due to an apparent allergic reaction.

2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.

3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.

4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, 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.

5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.

6. 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.

7. 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.