Home / Health / Adrenaline Delay Kills Girl, Coroner Warns Wales
Adrenaline Delay Kills Girl, Coroner Warns Wales
9 Mar
Summary
- Four-year-old Summer Rae Mant died after delayed adrenaline administration.
- Coroner issued urgent safety warning to all Welsh health boards.
- Lack of standardized crash trolleys cited as a contributing factor.
An urgent safety warning has been issued to all health boards in Wales following the tragic death of four-year-old Summer Rae Mant. The girl suffered irreversible brain damage and subsequently died after medical staff at Prince Charles Hospital in Merthyr Tydfil experienced delays in accessing a life-saving adrenaline shot during a cardiac arrest.
The coroner's investigation revealed "missed opportunities and sub-optimal care" during the incident in March 2024. Summer, who had a rare condition called Mirage syndrome affecting her ability to fight infections, experienced cardiac arrests while being moved between breathing machines and during intubation. A significant delay in administering adrenaline, attributed to a lack of standardized crash trolleys and junior doctors' unfamiliarity with hospital setups, contributed to her brain injury.
Summer never recovered meaningfully and passed away six months later in September 2026 from multi-organ failure. The coroner stressed the risk of future deaths unless standardized crash trolleys are implemented across all Welsh hospitals, particularly where junior doctors rotate. Summer's family, who described her as 'adventurous and fun-loving,' have been devastated by the outcome.
