The four-year-old from Merthyr Tydfil died six months after medics were unable to quickly access life-saving adrenaline during a cardiac arrest – a coroner has now issued the warning following her tragic death
The tragic passing of a “spirited and affectionate” four year old girl has prompted a coroner to issue an immediate safety alert.
Summer Rae Mant, from Merthyr Tydfil, lost her life six months after a hospital failed to locate a crucial medication in time to prevent her from suffering irreversible brain damage.
Medical staff at Prince Charles Hospital were unable to swiftly procure adrenaline needed to resuscitate Summer following a cardiac arrest. Coroner Rachel Knight has since penned letters to every health board across Wales, demanding measures be taken to avert similar fatalities in the future.
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“Summer’s death has utterly shattered her family, and the distressing revelations from the inquest only underscore the absolute tragedy that has unfolded,” expressed Katie Wile, a clinical negligence solicitor assisting the family in their quest for answers.
“The shortcomings pinpointed by the coroner starkly reveal that Summer should never have endured what she did, and no family should have to grapple with such repercussions,” added the Slater and Gordon solicitor reports North Wales Live.
Summer was born with a rare disorder known as Mirage syndrome, which compromised her immune response. Following the onset of a severe chest infection and virus, she was admitted to the hospital in March 2024.
Whilst medical staff worked to transfer Summer from one airflow device to another, her blood oxygen levels plummeted dramatically, triggering cardiac arrest.
Summer was eventually resuscitated but suffered an irreversible brain injury, never making a meaningful recovery. In September 2024, six months after the incident, she died of multi-organ failure at Tŷ Hafan hospice.
The coroner expressed alarm regarding the hold-up in securing adrenaline during Summer’s resuscitation efforts. She 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, and junior doctors frequently rotate between hospitals and health boards, and encounter different set-ups.”
A crash trolley contains vital equipment required for urgent, life-preserving treatment during medical emergencies. Ms Knight acknowledged that paediatric crash trolleys are “necessarily different” from adult crash trolleys.
However, she concluded that it would be safer if there was “a single standardised version of each type” across all hospitals where junior doctors rotate. This would “minimise confusion at a time-critical moment”, she stated.
The coroner noted there were “missed opportunities and sub-optimal care” around the time Summer’s oxygen levels dropped, although she couldn’t definitively pinpoint “the precise contribution of the various factors”.
Calling for a Wales-wide overhaul of crash trolley provision, she warned: “In my opinion there is a risk that future deaths will occur unless action is taken.”
A Gofundme campaign amassed over £5,000 to alleviate the financial strain on Summer’s parents as her health deteriorated in the months leading up to her passing. Summer’s grandparents fondly remembered 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”.
“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.”
Ms Wile is hopeful that the coroner’s ‘prevention of future deaths report’ will help ensure “no other families have to endure such unimaginable pain”. “Our work continues in supporting this family in holding [Cwm Taf Morgannwg university health board] accountable for the loss of their beloved Summer,” stated the solicitor.
A representative from the health board expressed: “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.”
