Harrowing account of Martha Mill's death at 13 in Guardian today

[StaplesCorner]

I don't think there's another thread on this already I did a search, but I think this needs to be widely read - there seems to have been no lack of NHS resources here whatsoever, but consultants' arrogance by the spade; shades of This is Going to Hurt? Every parents' worst nightmare:

www.theguardian.com/lifeandstyle/2022/sep/03/13-year-old-daughter-dead-in-five-weeks-hospital-mistakes

@XelaM I couldn’t agree more with you. It is a heartless response. It must have taken this mother a tremendous amount of courage and strength to write what she wrote. And despite everything that happened she didn’t actually bash the NHS or the government. She wrote eloquently, factually and with dignity and wisdom.

@QuebecBegnet- is that true? That it's only in the last decade that these checklists have been introduced in UK hospitals?

And clearly not accepted in all hospitals.

This is utterly shocking.

@QuebecBagnet - sorry for misspelling.

I can’t stop thinking about her. After I read it I felt like I’d been hit by a brick
wall.
I noticed lots of my favourite doctors (ICU consultants) were sharing the article on twitter. These are people I followed when covid hit. It’s good they are sharing it and acknowledging it.

I hadn’t heard about the idea of the island before. It’s absolutely right. I’m on the island. But being on the island because of such catastrophic failures must be an excruciating hell.
What a beautiful girl.

Oh absolutely. Only within the last decade.

same for the NEWS scoring charts which are the charts which give an overall number to someone’s observations and the higher the number the sicker they are. It helps pick up sepsis. So now I can ring a doctor ans say “I’m worried about x, she’s scoring 6” and that should convey how serious it is. Each level of scoring has a necessary action against it, so repeat obs in an hour, or get reviewed by a doctor within 30 mins, or start a sepsis bundle.

This is so so sad. There should be a way of holding staff accountable for their own mistakes. The consultants should face manslaughter charges or, at the very least, negligence charges. Their not following procedures killed Martha.

The fact that important email trails went 'missing' is just awful.

Poor Martha. She must have been so scared.

But her mother has nothing to feel guilty about. I feel for her.

I'm starting to think that each hospital and NHS trust needs some kind of Line of Duty-esque internal investigations unit, staffed by medical professionals with no fear of making enemies and unhindered by others closing ranks. Institutional changes need to be made but there also needs to be accountability and consequences for incompetent individuals.

There is one of these for maternity cases now. They’re area based and independent to the hospitals l

@RunningSME

You are of course correct sometimes one doctor does get it wrong what’s on usual in this case is for so many medics to get it wrong and to go against their better judgement I don’t believe for a minute that the nurses weren’t aware she was deteriorating.

Looking at this from an ex-aviation background and having done the sort of training being discussed (CRM) that also struck me as very very odd.

CRM training wasn't simply about bringing a few individuals down to earth, maybe about making them more approachable. The training in it's various forms was also designed in part to ensure everybody on the crew realised they responsibilities when it came to safety.

That meant everybody really should take an interest in events and report/discuss any concerns up the management chain/to the pilots on the Flight Deck, rather than ignore something because "it wasn't their aisle" (cf. some aspects of the Kegworth 737 accident).

Not quite true about the NEWS type systems, our local one is called EWS (early warning system) and has been in place for nearly 15 years now.

www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

NEWS was first produced in 2012 according to the above link.

I don’t know whether any of you watched the excellent and harrowing TV show “Bodies” some years ago but it felt authentic and explains how these terrible cases happen. It is mostly ego.

I find a mention of “duty of care” or “negligence” often brings Drs up short but going forward I think if I ever found myself in a very grave situation I would be very obviously taking notes so that the Drs would be in no doubt that I was making a record.

The rock and a hard place though is that we worry that if we “upset” them by being what they see as demanding, that we won’t get the right care. If we roll over and are seen as weak and unassertive we worry we wont get the right card.

The tragedy for Martha’s parents is that they were clearly advocating politely and firmly and it met with the same response.

The NHS is like a religion. Never to be questioned. And because people perceive it to be free they are grateful for their treatment. But Uk residents pay for this treatment through there taxes. It’s not something to be grateful for. We need to move towards the European insurance style system.

This - 100%

Both a harrowing and a terrifying read.

That poor family.

To know poor Martha was so neglected must be beyond devastating.

So cavalier with her life.

I never thought I would say this but the state of the NHS is so dangerous and shambolic that I favour an European style insurance system too.

Bodies and Cardiac Arrest were both written by Jed Mercurio (he of Line of Duty). He is a former hospital doctor. I remember the medics at my college have a DVD box set of Cardiac Arrest and commenting on how accurate it was.

as well as the recent This is Going to Hurt

*had a DVD box set

Bodies is currently on Netlfix

I agree, we need an insurance system. To say this out loud is to be met with cries of "Facist" and "Tory scum" though

no, the consultants need to learn Humility

Thanks for sharing. I read it yesterday night on the Guardian - really sad and I could not sleep thinking of what Martha and her family went through. It is probably more common than we think as not always the people involved can share what happens to them in the way Martha’s mum did.
The night my child was born at King’s, another baby died, the mum was lying on the same ward with happy mums and near me and I could hear when the doctor came to say that also his twin was going to die - I do not know if it was preventable or not - it was 2016 - what I know is that my child suffered a lot during birth - from 6 am to 12 pm day after with midwifes only - he passed meconium and the doctors were never told it by the midwife. She did not even write it on the notes, which we cannot read anyway. It became an emergency - the consultant was visibly angry with the midwife and there were so many doctors for us at the end - today he has special needs and I will never know what the impact of that birth had on his life.

That poor lady. I couldn't finish the article it was too sad.

I found it bad enough when my dd broke her arm and no one would let her into a&e. A&e were insisting on an appointment through 111 because of covid rules, 111 insisted my dd was fine because there didn't sound as if there was enough bruising.
When I got to a&e after a 4 hour argument to 111 my dd had gone silent in pain. The a&e nurse said she looks fine to me, when actually it was by now 11pm and my 6yo was in so much pain she'd silently curled up on my lap.
By 1am we'd finally seen the break on an X-ray and the same nurse couldn't manage to get the correct items needed to cast the arm. The doctor got so fed up with her she walked off to get it herself.

The whole experience terrified me. My only experience of hospitals is giving birth and even then no maternity nurse would check me to see if I was giving birth because I was able to talk and apparently not in enough pain even though I felt I was. I gave birth 30 mins later with no pain relief. All of it leads to extreme anxiety around never participating in more daring activities as a family. I know that's not going to prevent every accident but I feel I may as well try to avoid the nhs at all costs. There really isn't much of an alternative when it comes to ICU and a&e either even if you have insurance.

I don't want to be forced to rely on the NHS unless I absolutely have to. I truly don't believe it's fit for purpose for whatever reason, but the reason doesn't matter in the end. If you end up a situation like this poor girl you're effectively done for.

Heartbreaking, poor Martha! And brought back so many memories of what happened to my mum. Whilst in ITU she had amazing care but for some reason whilst they were bringing her out of her induced coma they bypassed HDU (where she would have had 2 to 1 care) and sent her to a general ward.

That night she was so confused she fell out of a hospital bed twice cracking her head on the floor so hard it gave her a huge head injury.

No one even told us until 24 hours later when due to the pressure on the brain from her head injury she lost the use of the right side of her body, she then died very suddenly.

An inquest was held where the hospital sent their own solicitor to try and argue that it was my mums fault (!) the coroner saw through it luckily and recorded a narrative verdict, cause of death directly related to a hospital fall.

My mum was only 57 and until that time was a very youthful lady full of life.

It’s such a heartbreaking piece. That poor mother living with that “what if?” feeling.

Several members of the care team involved in my youngest DD’s care absolutely hate me because there has been a few instances where we’ve clashed.

On one occasion she had a test done that was basically done to prove me wrong, with an air of threat that I’d be kicked out the hospital if I stepped out of line again, and Billy Big Baws in charge was visibly livid when the results came back and I was right. Even one of the nurses told me to be careful because he “doesn’t like being proved wrong”.

I have a notebook with me every time that we’re in, or at appointments, and I write everything down. It’s amazing how much clearer and proactive the staff are when you make clear you’re taking notes. Especially when you ask “and who made the decision not to do that test/give those meds?” with your pen in hand.

This is heartbreaking and terrifying. What a well written and eloquent article. Martha sounds wonderful.