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

They value the patients more in a private setting, literally you aren’t seen as being scum under their shoe because you have the money to pay therefore you are worth saving.

you are a concerned mother rather than a hysterical banshee trying to tell them how to do their job.

I have been in the receiving end of attitude from NHS dentists with my children who obviously didn’t see the car I drove in to the setting and the kids were in their play clothes so the Penny clearly didn’t drop that we were an affluent family who were just using the NHS because we’ve been referred here.

The difference when taking them to a private setting where my credit card had to be swiped before the kids were seen was worlds apart.

Thank fuck for that. You hardly sound human tbh

That's not what the coroner said. "If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries." www.judiciary.uk/wp-content/uploads/2022/03/Martha-Mills-Prevention-of-future-deaths-report-2022-0063_Published.pdf

That is also not what 2 of the doctors involved said, including Prof Checked Shirt, who at the time told PICU not to go and see the patient but at the inquest said that she should have been moved to PICU over a week sooner.

Yes, people make mistakes. Yes, hindsight is a wonderful thing. Had she been moved to PICU then maybe she would still have died. But if she had, then knowing that the doctors had done everything they should have and the parents had not "failed" her by failing to fight her corner would have been a "better outcome" than what actually happened.

But she wouldn’t have.

You’re really not getting this are you?

Given it’s a brand new account I suspect a friend/supporter of one of the consultants has turned up if I’m honest.

Absolutely heart breaking. As a parent who has had a seriously ill child I absolutely agree with Martha's mother - ask questions/ find out who is in charge of their care. I had too many instances of Doctors dismissing my concerns and questions until I pushed back which meant my child got the care they needed. I equally had this experience when my DF had a stroke and was just left - the Dr in charge of the department said the scanner had broken and he would be looked at in due course I insisted on a transfer to a hospital with a working scanner - 10 minutes later he was wheeled into the "broken scanner" which showed larger clots that needed urgent treatment. DF is Irish and it was noted in his admission notes they believed he had been drinking as his speech was slurred (couldn't be a stroke symptom of course) - his admission was at 8am and he was teetotal.

I take the point that professionals cock up - we are all human there was an awful case where an error by one over worked junior doctor caused a death and doctors protested when an individual was going to be tried for man slaughter. This is not that though is it? It was systemic failing over and over again despite protestations by intelligent informed parents who were dismissed.

Surely the least worst result is not pillorying individuals but stepping back “how can this never happen again” approach. Maybe I’m being naive though.

@MsTSwift

Surely the least worst result is not pillorying individuals but stepping back “how can this never happen again” approach. Maybe I’m being naive though.

It's called a "Just Culture" in some industries - doesn't always work as advertised but the idea is to at least not penalise those who have made/reported a genuine mistake.

skybrary.aero/articles/just-culture

There should be a black box thinking it was introduced in the 70s are believe and highlighted and pushed during the 80s and 90s within the medical profession certainly within America anyway.
but all of this is irrelevant when a doctor alters a patient’s medical records, unforgivable.

I read that as a Jesus Culture. Better get my eyesight checked 🤦🏻

The most chilling thing I've read but it's so real. My daughter almost died last year due to hospital negligence. She caught covid September last here and pretty quickly couldn't move her legs or eat. It took two weeks of being turned away from a&e and pacu. Our gp wanted her admitted three times before she was taken seriously. It took four weeks in Glangwili where nobody would consider what we were saying about her legs being rigid. They left her without an iv, couldn't competently fit an ng. Until it got to a point where a fresh doctor said this child needs to go to intensive care. She was ventilated and sent in an intensive care ambulance to Bristol picu. The nurse told me in the corridor in Glangwili that my 11yr old might die. I had to be injected twice I was hysterical because I had told them for weeks she was unwell. She has been left with severe ptsd.
This story will live with me forever, what a brave mother to share this.

This story has really affected me. As individuals we are so at the mercy of institutions. I agree with a previous poster that the mother could not have done more. In fact I suspect a dynamic developed of shutting her down because she was intelligent and informed (and a journalist). I can also smell the misogyny. I’ve made a mental note to get dh to speak with medics in this type of scenario because I already know he gets better ‘outcomes’ - thankfully for lesser complaints

This is a truly awful story but unfortunately I am not shocked. I also experienced the awful NHS system a few years ago where I repeatedly presented with symptoms of internal bleeding but I was ignored and sent home. Escalated into emergency surgery where I lost a lot of blood and could have died. The hospital did a great job of burying all the doctor's mistakes afterwards. RIP to that little girl and my heart goes out to her mother.

Yes! It wasn't for patients, apparently. I'm a registered nurse too but honestly, it's just a book!

The point about the bleeding being unusual for her condition was that the bleeding was unlikely to have been caused by her injury.

We have very clear guidelines about what symptoms should trigger a sepsis pathway.

After years of good treatment for an ongoing condition I had a bad enough experience with a new junior doctor that I wrote a complaint letter to PALS about it. First time ever. I was careful to say I did not expect an apology, but I wanted it known and how it made me feel.

When I got the reply I was stunned at how both she and her supervisor (who hadn't even been in the room) not only denied it happened, they made up a conversation that didn't happen. Two medical professionals lying on record.

The trust with that team is now gone and I've had to move my treatments to another, much further away hospital.

I made a second complaint about the fact that they lied and then spent months and months chasing PALS to confirm it would go on her record in case there were further complaints.

And if everyone got exemplary treatment, far fewer people would die. THAT'S the goal.

Martha didn't die because of innocent mistakes that anyone could make. She died because people were arrogant, neglectful and did a poor job. As the coroner's report shows. So your 'subjective account' crap belongs in the bin. The most subjective poster here is you, wilfully ignoring and glossing over relevant points.

As for "There is no knowing if being in PICU would have had a better outcome" actually, yes there is, because it couldn't have been worse, could it? At least if Martha had been transferred to PICU, and still sadly died, it would have been trying the best for her.

You've made yourself look both ignorant and unfeeling with your posts here @ITalktotheTrees. Thankfully you aren't a clinician.

Martha’s story is heart breaking but beautifully written by her mother, she has created a legacy for her daughter that will live on in the hearts of everyone who has read this article.

The hardest part for me to read is that they didn’t suspect sepsis because she was lucid and not acting abnormally…..

About 7 years ago, I had sepsis and while I had it I was still able to drive, cook and look after my 3 month old baby albeit with crippling bouts of pain and a high fever.

When I was finally admitted to the hospital, like Martha I was still lucid and the Drs missed the sepsis as my fever went up to 42c with the worst shivers and shaking I’ve ever experienced. Thankfully, they finally caught it while I was in septic shock and rushed me to the operating theatre, I ended up in ICU where I got the antibiotics I needed and they saved my life but to this day I still have trouble processing how close I came to not making it.

My heart goes out to Martha’s family and anyone who has been affected by sepsis, coincidentally September is sepsis awareness month so please do check out the campaign from www.sepsis.org for more information.

I worked as a Nurse for many years. I remember one day a patient being transferred to our ward from an outpatients clinic. The minute she arrived she was in severe pain around her liver. I begged the registrar to see her straight away but she arrogantly said she was too busy and would admit her later. I got strong analgeisia prescribed. The registrar said to me at one point " do you think X consultant would have sent her across here if she thought there was anything acute going on ? ". She made me feel really stupid for expressing more and more concern for this patient. She did get seen but was dead within a few hours from presumably some kind of acute event/ bleed. I doubt anything could have been done ( cancer patient), but I will never forget that Registrars arrogance and my feelings of helplessness literally begging for her to be seen and being dismissed. I no longer Nurse now thank god.

My niece nearly died as a toddler. Her father is a doctor (but not a paediatrician) and suggested to the hospital team what he thought was wrong. He was dismissed. Several days later niece was blue lighted twenty miles to specialist children's hospital. Her father again said what he thought was wrong and was again dismissed. Three days later they performed an emergency operation, on a bank holiday Monday evening, for exactly what her father had suggested was wrong nearly a week earlier. Care in ITU was excellent. But the operation should have happened days before and DN would have been less poorly when it was done and recovery would probably have been quicker. Six weeks later symptoms typical of a complication developed but again her father and mother were told at the local A&E that the presenting illness was a coincidence and that they were being over anxious and should go home. They instead took DN to the specialist children's hospital where they took the symptoms more seriously that time and another operation, which was needed as it was indeed a complication of the first operation, was done in a more timely manner. I have never seen a child look like DN did before the first operation and I pray I never do again.
My cousin's two year old daughter died due to medical negligence following an operation. The hospital apologized but that didn't bring her precious daughter back. She would have been nineteen this spring and her mum still misses her greatly. She has had three sons since but her daughter is gone. My cousin didn't sue the hospital, she wanted the surgeon to learn from the mistake, not to receive a monetary pay out. My cousin said she didn't want another mother to lose a child that way. My uncle, her grandfather, visited her grave every week until he died, the loss spreads beyond the parents on their sad island.
@ITalktotheTrees this is why people need to Google and ask and question and take notes because doctors aren't perfect. Most are capable, dedicated and hard working and some are brilliant but some are arrogant and dismissive and incompetent. As a patient or relative you don't know the difference unless you question.
Merope Mills is incredibly brave to have written this article about the awful, tragic and avoidable death of her lovely Martha. She should not feel any guilt but of course always will. My DD2 is almost exactly the same age as Martha. As a previous poster said she did I too gave DD an extra hug yesterday.

Rip martha. So much arrogance in the nhs and a terrible waste of a bright life. If Martha's family are reading this i am so so sorry that this has happened to you and martha.

Thank you for trying to raise awarness. My mum was a nurse and always said never trust what anyone in the hospital tells you. It is near impossible to fight against them though and entirely reasonable to trust what you are told.

My fear is that hospital managers now trot out the 'lessons learned' line and a series of recommendations about system failures and improvements are made. Who checks if they have been followed? Who shares them
Beyond the hospital?
Several doctors failed to follow guidance and policy.
No nurses challenged them.
Cultures are harder to improve than any other 'system' so what is being done about this?
The health regulator is weak and hospital inspections are overseen by doctors who of course protect their profession. All these 'independent bodies' and serious incident investigations and public inquiries are costing a fortune and yet they fail to really challenge and demand a culture change .

www.bbc.co.uk/news/health-62764409.amp
this story was on the news this morning. Obviously not connected to Martha’s case, but If a surgeon working for the Care Quality Commission can’t safely raise concerns the whole actually can?

then who

Goodness that has made me properly cry. Poor Martha and her family. What a beautifully-written piece by her mother, she paints Martha's personality so well for those of us who never knew her. But it is terrible to look back and read about what so clearly went wrong.

I am a doctor and I had a very very near miss with my own sepsis a week or so after having my first baby, the entire ward of staff missed it and it was only when I told them I felt so unwell that I knew something was badly wrong, that they started to take it seriously (temps of 42 but eating, drinking and coherent) so I can entirely believe that Martha's family and other families were not listened to and no health care worker thought to challenge the management plan. The narrative everyone was following for my illness was that it was "just a UTI" (it most definitely wasn't) but once that path is set, people can become blinkered to what is changing in front of their eyes.

For what else is available to help families, yes there is PALS but I doubt they'd be around out of hours, weekends or bank holidays and they are not an emergency response team. I seriously considered calling 999 when I was lying in my hospital bed in a side room with my concerns being brushed off and I was thinking I might die alone in there, no idea if anyone would have attended but they might have flagged something up to the ward I suppose. I guess ringing hospital switchboard and insisting on speaking to the highest level of on call clinical manager might be an option too...but there's no doubt hospitals and Trusts will close ranks, "lessons learnt", "sorry that you felt upset" non-apologies etc. The one treating me on that occasion did, and the one where I work does too (I am a doctor so I know the phrases that end up being sent out in these letters, legal team will be checking them too to avoid any admission of liability)