Source · Prevention of Future Deaths
Summer Mant
Ref: 2026-0118
Date: 27 Feb 2026
Coroner: Rachel Knight
Area: South Wales Central
Responses identified: 0 / 10
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A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Date
27 Feb 2026
56-day deadline
24 Apr 2026 est.
Responses identified
0 of 10
Coroner's concerns
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
View full coroner's concerns
During the resuscitation of Summer at Prince Charles Hospital in theatre following intubation, there was a delay in obtaining adrenaline. 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. Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate, to minimise confusion at a time critical moment.
Report sections
Investigation and inquest
On 26th February 2026, I concluded an inquest into the death of SUMMER RAE MANT. I reached a narrative conclusion as follows:
Summer Rae Mant was born with MIRAGE syndrome which amongst other things, impacted her ability to fight infections. She developed a severe infection and virus and whilst an inpatient at Prince Charles Hospital Merthyr Tydfil on 17th March 2024, reached the ceiling of ward-based care. During an attempt to switch between high flow nasal oxygen and the CPAP machine on 18th March, there was a rapid desaturation which led to a period of hypoxia and a cardiac arrest. Following this, there was a further arrest during intubation, with another period of hypoxia of up to 8 minutes duration. These events of 17th and 18th March likely led to an irreversible hypoxic brain injury. Summer was transferred to PICU in Bristol and subsequently Cardiff, but never made any meaningful recovery. Aged 4, she developed a sudden multi-organ failure in mid-September 2024, with an uncertain cause. Sadly, her condition worsened, and a decision was made to provide palliative care and she died at Ty Hafan on 21st September 2024.
Although there were missed opportunities and sub-optimal care around the time of the acute desaturation on 17th and 18th March 2024, it was impossible to ascertain the precise contribution of the various factors, in the context of Summer’s MIRAGE syndrome and compromised immune system. The development of the multi-organ failure which directly led to death was likely multi-factorial in nature.
Her cause of death was: 1a Unexplained multi-organ failure in a 4 year old child with MIRAGE syndrome, following a prolonged inpatient stay due to an acquired brain injury from March 2024 following a period of hypoxia whilst being treated for parainfluenza virus and a superadded chest infection.
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
Summer Rae Mant was born with MIRAGE syndrome which amongst other things, impacted her ability to fight infections. She developed a severe infection and virus and whilst an inpatient at Prince Charles Hospital Merthyr Tydfil on 17th March 2024, reached the ceiling of ward-based care. During an attempt to switch between high flow nasal oxygen and the CPAP machine on 18th March, there was a rapid desaturation which led to a period of hypoxia and a cardiac arrest. Following this, there was a further arrest during intubation, with another period of hypoxia of up to 8 minutes duration. These events of 17th and 18th March likely led to an irreversible hypoxic brain injury. Summer was transferred to PICU in Bristol and subsequently Cardiff, but never made any meaningful recovery. Aged 4, she developed a sudden multi-organ failure in mid-September 2024, with an uncertain cause. Sadly, her condition worsened, and a decision was made to provide palliative care and she died at Ty Hafan on 21st September 2024.
Although there were missed opportunities and sub-optimal care around the time of the acute desaturation on 17th and 18th March 2024, it was impossible to ascertain the precise contribution of the various factors, in the context of Summer’s MIRAGE syndrome and compromised immune system. The development of the multi-organ failure which directly led to death was likely multi-factorial in nature.
Her cause of death was: 1a Unexplained multi-organ failure in a 4 year old child with MIRAGE syndrome, following a prolonged inpatient stay due to an acquired brain injury from March 2024 following a period of hypoxia whilst being treated for parainfluenza virus and a superadded chest infection.
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
Circumstances of the death
The Inquest focused upon:-
a. The events of 17th and 18th March; and
b. Summer’s cause of death .
a. The events of 17th and 18th March; and
b. Summer’s cause of death .
Inquest conclusion
Summer Rae Mant was born with MIRAGE syndrome which amongst other things, impacted her ability to fight infections. She developed a severe infection and virus and whilst an inpatient at Prince Charles Hospital Merthyr Tydfil on 17th March 2024, reached the ceiling of ward-based care. During an attempt to switch between high flow nasal oxygen and the CPAP machine on 18th March, there was a rapid desaturation which led to a period of hypoxia and a cardiac arrest. Following this, there was a further arrest during intubation, with another period of hypoxia of up to 8 minutes duration. These events of 17th and 18th March likely led to an irreversible hypoxic brain injury. Summer was transferred to PICU in Bristol and subsequently Cardiff, but never made any meaningful recovery. Aged 4, she developed a sudden multi-organ failure in mid-September 2024, with an uncertain cause. Sadly, her condition worsened, and a decision was made to provide palliative care and she died at Ty Hafan on 21st September 2024.
Although there were missed opportunities and sub-optimal care around the time of the acute desaturation on 17th and 18th March 2024, it was impossible to ascertain the precise contribution of the various factors, in the context of Summer’s MIRAGE syndrome and compromised immune system. The development of the multi-organ failure which directly led to death was likely multi-factorial in nature.
Her cause of death was: 1a Unexplained multi-organ failure in a 4 year old child with MIRAGE syndrome, following a prolonged inpatient stay due to an acquired brain injury from March 2024 following a period of hypoxia whilst being treated for parainfluenza virus and a superadded chest infection.
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
Although there were missed opportunities and sub-optimal care around the time of the acute desaturation on 17th and 18th March 2024, it was impossible to ascertain the precise contribution of the various factors, in the context of Summer’s MIRAGE syndrome and compromised immune system. The development of the multi-organ failure which directly led to death was likely multi-factorial in nature.
Her cause of death was: 1a Unexplained multi-organ failure in a 4 year old child with MIRAGE syndrome, following a prolonged inpatient stay due to an acquired brain injury from March 2024 following a period of hypoxia whilst being treated for parainfluenza virus and a superadded chest infection.
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
Similar PFD reports
Report details
- Reference
- 2026-0118
- Date of report
- 27 February 2026
- Coroner
- Rachel Knight
- Coroner area
- South Wales Central
Responses identified
Responses identified
0 of 10
10 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Apr 2026 (estimated).
Sent to
- Aneurin Bevan University Health Board
- Betsi Cadwaladr University Health Board
- Cabinet Secretary for Health and Social Care
- Cardiff & Vale University Health Board
- Cwm Taf Morgannwg University Health
- Department of Health and Social Care
- Hywel Dda University Health Board
- Powys Teaching Health Board
- Swansea Bay University Health Board
- Velindre University NHS Trust