The tragic death of an ‘adventurous, fun-loving’ girl after doctors were unable to quickly find a life-saving adrenaline shot has sparked an urgent safety warning from a coroner.
Summer Rae Mant, aged four, suffered irreversible brain damage and died six months later, an inquest was told.
Medical staff at Prince Charles Hospital, Merthyr Tydfil, South Wales, did not have speedy access to adrenaline to help resuscitate Summer after a cardiac arrest.
Coroner Rachel Knight has now written to every health board in Wales demanding action to prevent other deaths in similar circumstances.
The coroner also criticised ‘missed opportunities and sub-optimal care’.
Summer, from Merthyr Tydfil, was born with a rare condition called Mirage syndrome, which affected her ability to fight infections.
As few as one in a million babies are born with the condition.
After developing a severe chest infection and virus, she was admitted to the hospital in March 2024.
As staff attempted to switch Summer from one air flow machine to another, there was a rapid drop in her blood oxygen levels, leading to cardiac arrest.
There was a second cardiac arrest during intubation, when oxygen flow was interrupted for ‘up to eight minutes’.
Summer was eventually resuscitated but suffered an irreversible brain injury and never made a meaningful recovery despite being transferred to two different paediatric intensive care units in Bristol and Cardiff.
On September 21, 2024, six months after the incident, she died of multi-organ failure at Tŷ Hafan children’s hospice in Penarth, South Wales.
The coroner voiced alarm over the delay in obtaining adrenaline during Summer’s resuscitation and inadequacies in the hospital’s procedures.
Ms Knight said: ‘The incident occurred at night and it involved a skeleton staff including some junior doctors, fairly new to the hospital.
‘The delay in finding adrenaline was likely due to the fact that there is no standardised crash trolley (which carries lifesaving equipment to be used in a medical emergency), and junior doctors frequently rotate between hospitals and health boards, and encounter different set-ups.’
Katie Wile, clinical negligence solicitor from law firm Slater and Gordon, supporting Summer’s family’s fight for answers, said: ‘The failures identified by the coroner lay bare that Summer should never have gone through what she did, and no family should have to live with such consequences.
‘Summer’s death has absolutely devastated her family – and the alarming findings of the inquest only highlight the absolute tragedy that has taken place.
The inquest heard how a hospital crash trolley is stocked with equipment needed for rapid, life-saving care in medical emergencies.
Ms Knight accepted paediatric crash trolleys are ‘necessarily different’ from adult crash trolleys.
But, issuing a notice to prevent future deaths, she concluded it would be safer if there was ‘a single standardised version of each type’ of crash trolley across every hospital where junior doctors rotate.
This would ‘minimise confusion at a time-critical moment’, she said.
The coroner said there were ‘missed opportunities and sub-optimal care’ around the time Summer’s oxygen levels desaturated, although she could not be certain of ‘the precise contribution of the various factors’.
Demanding Wales-wide change on the provision of crash trolleys, she added: ‘In my opinion there is a risk that future deaths will occur unless action is taken.’
In Summer’s final months, a Gofundme campaign raised more than £5,000 to ease the financial pressure on Summer’s parents.
At that time, Summer’s grandparents described her as a ‘happy, adventurous, loving, cheeky, playful and very active child who had overcome so many obstacles with the wonderful care from her devoted parents and family’.
They added: ‘After nearly four years of constant and vigilant care she had just got to a point in her life where she was starting to eat orally, talk and was becoming more independent.
‘She loved reading books, playing with trains, baby dolls, construction toys and gardening.’
Summer’s family said they did not wish to comment further following the publication of the Prevention of Future Deaths notice.
Ms Wile said she hopes the coroner’s notice will help ensure ‘no other families have to endure such unimaginable pain’.
A spokesperson for Cwm Taf Morgannwg University Health Board, which runs Prince of Wales Hospital, said: ‘We offer our sincere condolences to Summer’s family.
‘Alongside health boards across Wales we are taking forward the learning from this case to make the necessary improvements within our hospitals.’
The inquest into Summer’s death was held by South Wales Central Coroner Ms Knight in February.
She concluded the youngster died of multiple organ failure.
