Summary
On 3 September 2021 assistant coroner Jonathan Stevens commenced an investigation into the death of Martha Mills, aged 13 years.
Martha sustained a handlebar injury whilst cycling on a family holiday in Wales. She was transferred to King’s College Hospital London and died approximately one month later. Her medical cause of death was:
- 1a refractory shock
- 1b sepsis
- 1c pancreatic transection (operated)
- 1d abdominal trauma.
Content
Coroner's concerns
Whilst at King’s College Hospital, Martha was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries.
- The bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based, unlike the adult system. It was put to the coroner very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal, with a higher risk of this sort of situation recurring.
- The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists. Evidence suggests that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments, and to ensure that there is pro-active paediatric intensive care outreach. However, the intended programme has stalled, partly because of the pandemic. It seems that there needs to be an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future.
Response from King's College Hospital
Further reading
Sharing her story in the Guardian, Merope, Martha's mother, gives a heart breaking account of how Martha was allowed to die:
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