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

what a horrible and stupid response. I feel sorry for the trees you talk to.

1. yes she is a journalist. I can only imagine how many horrible stories out there do not get shared or told. Heartless and stupid
2. you say doctors are humans. Yes and that is why we should be allowed to criticise them and demand accountability. They are not freaking gods. They should stop treating others like dirt.

we should stop feeling indebted or grateful, we pay a lot of taxes. I cannot opt out of paying taxes to pay for the private medical insurance instead.

my DD was in the same ray of sunshine ward a year earlier. What a horrible
place it was. We could not find a doctor or consultant to speak to, could not understand what was going on. We practically self discharged and run. My daughter still in the hospital blanket.

Key messages Martha’s mum wanted to share were for me: trust your gut, parents know when something is wrong, push for treatment, second option etc, Google.

Cried my eyes out reading this article. RIP Martha xxx

@ITalktotheTrees

what a horrible and stupid response. I feel sorry for the trees you talk to.

yes she is a journalist. I can only imagine how many horrible stories out there do not get shared or told. Heartless and stupid
you say doctors are humans. Yes and that is why we should be allowed to criticise them and demand accountability. They are not freaking gods. They should stop treating others like dirt.

we should stop feeling indebted or grateful, we pay a lot of taxes. I cannot opt out of paying taxes to pay for the private medical insurance instead.

my DD was in the same ray of sunshine ward a year earlier. What a horrible
place it was. We could not find a doctor or consultant to speak to, could not understand what was going on. We practically self discharged and run. My daughter still in the hospital blanket.

Key messages Martha’s mum wanted to share were for me: trust your gut, parents know when something is wrong, push for treatment, second option etc, Google.

Cried my eyes out reading this article. RIP Martha xxx

Absolutely haunting article. I genuinely fear me or DS becoming ill and having to rely on the NHS. By the grace of god this could be any of us.

I previously worked in a Trust and let me tell you, this happens all the time and never hits the news. Trusts pull rank muttering about lessons learnt with some action plan usually long forgotten. At its heart it’s the culture, and trying to change it is impossible. You can write all the processes and provide all the training and half the time these people will not absorb any of it. Because they have no interest in being told what to do by anyone and no one will hold them to account, in fact the system protects them.

I do worry about having to use public health care here. I've lived in Africa and it was better to be honest.

Don't forget that many people experience good health care in the UK.

And of course, Africa is a massive continent with a lot of variation in health care between different countries

@myyellowcar I agree with your post in part.

From what I hear from retired GPs practising medicine has changed but not for the better.

Years ago, doctors were trained to use their hands, ears and eyes. They examined patients, (because they had the time) listened to what they had to say, looked at their problem area(s) and used their skills to make a diagnosis.

Then along came the NICE (National Institute of Clinical Excellence) Guidelines. These were standardised protocols of "Best Practice" that effectively took away doctors' clinical autonomy.

So now GPs have 5 mins to see a patient and make decisions. So understandably, if the problem anything that can't be cured by a prescription, you get sent for a scan.

If you have the misfortune to drop dead in between the consultation and the date of the scan the GP can say "I followed NICE guidelines and referred Mr/Mrs/Miss Smith for a scan."

It looks like we will be heading to the situation in USA where doctors won't help someone who collapses in the street in case they get sued.

the point here though is that this grossly negligent treatment was due to nothing but ego and arrogance. It had nothing to do with financial or other pressures

There are a lot of issues raised here.

Re Martha, how tragic and appalling, that poor little girl and her poor poor mum.

Yes, we do need to listen to parents more.I think it is great when patients and relatives read up about conditions and always have tried to have a discussion at depth about concerns. However, I also chose to work in a speciality and as far as possible in a setting where there was the time to do that, and
from what has been written on here, it sounds as though the staff on that ward may have been more thinly spread. I wonder if rather than not bothering to see patients, the juniors may well have been covering othe hospital areas/ called away to other things. That is potentially a high level management issue. Often, with these things, the apparent problem, for example, is a mistake by the more junior HCPs but the real issue is that the cover rota is badly organised by higher management, perhaps for financial reasons, so that it would be very difficult to cover all the wards properly out of hours. (I write as someone who has spent many hours in committees arguing for resources to be spent to cover patient care properly; I resigned when one Trust tried to reorganise my work in a way that I thought would be unsafe and then watched sadly from another Trust at how things turned out)

We absolutely have to have indemnity insurance, because if something goes wrong, say for a new born baby, there might need to be a very large payout for that person, for their needs through life, and a doctor might not have that money themselves. Yes, the NHS needs to have indemnity insurance, doctors usually have their own, expensive indemnity insurance of their own on top.

Of course we want a service where mistakes aren't made and where there are systems to pick up shortfalls. At the same time, HCPs are all human and mistakes will be made. Yes the catalogue of oversight was appalling, and the mum in the article was very eloquent about her terrible experience. But for us to have hospitals and paediatric doctors, we have to have a way to teach and support staff through mistakes, otherwise we wouldn't have the staff or the service at all. There needs to be accountability and responsibility, but it needs to be broadly constructive rather than punitive. I am writing this, I admit, as a doctor, though I read the article really as a mum with similar aged children to Martha.

It came over, reading the article, as though the doctor who went off to a conference somehow shouldn't have been going there; but in fact medical staff need to be informed and to learn. Precisely to make the level of care better.

Adam Kay wrote about how his experience of a case where things went wrong led to him leaving the profession, but if every doctor who had a case where things went badly then left the profession or was drummed out, where would we be?

You've tried hard to be reasonable in your post @herecomesthsun but it's noticeable that you are still avoiding any comment that holds the most senior doctors in this scenario responsible for their failings - and there clearly were serious failings on their part. That in itself indicates to me the depth of the problem here. You're willing to pick up the peripheral issues, but not the central one of blinkered, harmful staff.

Yes, culture needs to change. Bad apples like this, though, need to be removed, not protected and tiptoed around. If it even happens with doctors posting on Mumsnet, how will it ever be dealt with in real life?

These consultants, at a London Teaching Hospital, are probably some of the most senior and experienced in the country (I don't know who they would be personally). If you get rid of senior paediatric consultants every time you have an unexpected death, or because they are too pompous, or because they didn't pick up on a diagnosis quickly enough, you wouldn't have many left; and we don't have enough paediatricians to start with.

I completely agree that we should do whatever we can to make paediatric care as good as it can be. I think that as a doctor and as a mum. However, getting rid of a lot of the consultants probably wouldn't have that effect. Probably the reverse.

@herecomesthsun the crucial issue here, and your post has failed to address it, is that this tragic death arose as a result of arrogance and negligence. It was not staff being “thinly spread” or any of the other issues to do with financial and time constraints. This is a specialist unit where, these posts have shown, the Consultants viewed a referral to intensive care as somehow casting doubt on their competence. There was absolutely no excuse for the Dr who was contacted at home not to mention very obvious symptoms of sepsis. That was negligent and, given the culture we have all seen described, I think it borders on criminal negligence. That doctor remains in post. He sounds like a contemptible human being as well as a very dangerous practitioner.

I am not trying to berate you personally but unfortunately many of us on this thread have had the experience of having suffered serious medical negligence, rudeness and condescension. The response when things go wrong is a closing of ranks, empty apologies and a refusal to accept responsibility. We need a wholesale culture change and we need to demand it in the same way that we are demanding it of the police.

I would also suggest that the evidence we have here is the beautifully written and heartbreaking account of the mum. There will be other perspectives.

(I'm not involved in this case, and thankfully had no such incidents in my career, but the narratives of such cases are usually complicated).

I would refrain from calling for anyone's head on a plate without more evidence.

IMHO (not a medic) trying to pin the blame for this entirely on one individual, whist inevitable is a bit simplistic....

It's all very well pillorying, rightly or wrongly, one doctor but if this fatality had happened in another context in at least one industry questions would probably being asked of the whole team, right down to and including perhaps some of the nursing staff.

would refrain from calling for anyone's head on a plate without more evidence.

Insulting to the author to suggest this is what she's done. It is already a complicated narrative and she presents that. She doesn't need to be on your side of the tracks to know this is complex and indicative of wider problems. Not sure why you'd want to paint this as a short sighted parent villifying one doctor when it's anything but and the hospital investigation outcome is broadly supportive of her narrative. Patronising much.

It came over, reading the article, as though the doctor who went off to a conference somehow shouldn't have been going there; but in fact medical staff need to be informed and to learn. Precisely to make the level of care better.

No it didn't. It came across, quite rightly, that he shouldn't be heading off to a conference in a manner that would undermine care for patients left behind. I'm sure the writer is quite capable of appreciating the importance of professional development. However not at the cost of the slow and unchecked deterioration and utterly preventable demise of her child, naturally.

@Butterdishtea No, not the bereaved mum. I was referring to the other comments on this thread calling for heads on a plate by suggesting that bad apples should be culled and doctors should face damages without limitation and without protection from their employers etc.

Also, @Butterdishtea the conference attendence happened after the sad loss of this little girl, so did not have an immediate negative impact on care in terms of this time line.

More generally -
Thinking about it, there can be referrals to the GMC, which the family and also any other party, such as concerned colleagues, can make. That would be another place to consider the roles of the individual clinicians and the various factors at play. The GMC, if investigating, would have access to hospital records and witness statements as we don't on here.

Another consideration often taken into account is whether another doctor might reasonably have acted in the same way given the circumstances and the information to hand. So another independent expert might be asked to assess that.

The GMC can take away a doctor's registration or put limitations on their practice. Also, the Trust, as a doctor's employer, can put in place requirements (or terminate employment). So I guess those structures are already in place.

Literally bullied out for raising his head above the parapet

This happened to my friend, an experienced doctor who tried to whistle blow about a more senior consultant who was making dangerous mistakes and trying to force her to be complicit in covering them up.

The closing of the ranks and the way her colleagues turned on her was breathtaking. They told her she would find herself unable to find work in her field. Her career, along with her mental and physical health have been destroyed.

herecomes

Yes, I'm aware of what you've outlined. I'm not sure why you feel the need to educate me. Are you this patronising to your patients?

I personally don't think the GMC is at all disposed to supporting members of the public who have complaints. There are various aspects of their system that is geared towards the protection of the public perception of the doctor rather than the patient involved. But I have things to do and no desire to be talked at thanks.

You are a fool if you think you're cleverer than Martha's mum and it rather seems as if you do. The arrogance and disinterest in your posts is astounding. Perhaps this would be a good time to get off Mumsnet and do some of that reading you overworked medics never seem to find time for.

I think you're misrepresenting my comments here @herecomesthsun I didn't say 'doctors should face damages without limitation and without protection from their employers etc.' Nor did I say doctors should be punished for unexpected deaths. I was talking about specific doctors in this specific case, where the official investigation agrees with the general tenor of the Guardian piece in saying that there were real issues with their approach to this case - which don't come down to innocent mistakes being made, time pressures or accidental overlooking of information. I don't want a general witch hunt against doctors. I do think the senior doctors in this case did their job poorly when they could have freely made different choices, and that should have serious consequences for their future in medicine. Do you disagree? You seem to be looking for every possible reason to excuse their behaviour.

Well, since I have fairly recently retired and have not yet returned to work, though I may, I have the time to respond.

What I said was that there are procedures in place to deal with bad decisions and queries about conduct. Those already exist.

@Shakethedisease There have been various comments from different posters on here about what should be done to doctors; uncapped damages was one suggestion. I was trying to discuss the comments generally.

I'm not excusing the behaviour - it sounds as though a lot of important signs and symptoms were missed and the hospital really needs to address that. - but was making some general comments about process in case it was helpful for some.

It is absolutely boggling to me that successive hcp's including very senior consultants have missed Martha's sepsis. It was absolutely, blindingly obvious - even to a non-medic - long before any action was taken.

The consultant posting a picture of his hotel room view was absolutely grossly insensitive. If men like like this are rising to the top of the profession, there is something very wrong with medical education.

Also depressingly unsurprising to see that handover notes went missing.

I sued for delayed diagnosis in 2006 - now I take my husband (NHS consultant) to all my appointments, take notes, ask who the accountable/responsible person is to make sure that x happens, request copies of all referral letters and ask them to repeat anything that I think has been fudged. It really seems that NHS staff provide as little care as they think they will get away with - and the nation's naïve adulation of the NHS facilitates this.

the difference in treatment of these doctors and the treatment of Dr Bawa Garba who both essentially missed sepsis and sadly both children died is shocking.

@Anunusualfamily Actually there are strong similarities too - remember the consultant notionally supervising Dr BG who (iirc) just fucked off to practice in Ireland and escaped any sanction? The egotism that we can see in Martha’s case is right there.

Dr BG at least stuck around to face the music and was convicted of GNM. Tbh I wouldn’t want any of them near my child if they were sick. But if Martha was under supposedly excellent Oxbridge educated senior doctors, just imagine the quality of those practicing in DGH’s! Terrifying.

Dr Bawa Garba was working under extreme pressure covering the jobs of 3or 4 doctors over several different wards on different floors of the hospital on her first day back from maternity leave as a middle grade registrar with no induction no effective clinical supervision and the iT system was down in a hospital with a culture that allowed parents to give their child medication that she had not prescribed.
The situation can’t really be compared to multiple senior registrars and consultants working on a specialised ward with a parent asking could this be sepsis and ignoring it.
But she was the one convicted for being negligent.
i would trust her over any of the others