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

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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

Can hardly read it. So devastated for the family and cross with the egos of those who didn't do the right thing. Lovely, beautiful girl.

@Anunusualfamily BG was convicted of gross negligence manslaughter despite all of the things you mention. She has no more place on a pediatric ward than any of the buffoons involved in Martha’s care. However, she at least faced up to the consequences of her actions, unlike any of the consultants involved in either case.

Correct me if I’m wrong but it seemed to be one particular Consultant whose ego was getting in the way and preventing him from making the best clinical decisions? There were mistakes amongst some of the junior team (poor example from their Consultant?) And blasé attitude from some nurses (scared of questioning that Consultant?).

So no it’s not about sacking a whole load of senior Consultants. Prof or no Prof, big London teaching hospital or small District General, we cannot tolerate this kind of unprofessional lazy terrible decision making.

@herecomesthsun unexpected death is a glib euphemism for death due to gross negligence. Don't gloss it. It does your profession no favours.

To me, doctors can absolutely make ‘acceptable’ mistakes which don’t mean they’re unfit (unless repeated) - missing a very rare diagnosis, something very unusually presenting, or like what happened to Dr Bawa Garba - being set up to fail by a multitude of factors outside of her control.

But this wasn’t that. This was a red flashing beacon which they all ignored. Why? They need to be providing very detailed answers as to how Martha’s care went so tragically wrong. And if there is no plausible reason as to why they missed this, they need to be demoted and forced to re-qualify for consultant status.

@MissyB1 Presumably if you think that harsher measures were warranted in this case, you might also think that harsher measures would be warranted in equivalent cases?

If we are talking about lowering the bar for sacking doctors & consultants, for example, rather than changing practice and issuing advice, then we would end up with fewer doctors and consultants, when we already are understaffed, That was the point I was making.

@herecomesthsun the difficulty is that your posts come across as defending the indefensible. You are clouding the issue. The doctors here - most notably a senior consultant - were negligent. Not overburdened, not underfunded but negligent.

With the greatest respect you’re doing what we are all saying doctors do - close ranks and trying to justify and explain. I don’t know how many more times this needs to be said but the consultant was arrogant and negligent. You appear to be suggesting that the NHS should have arrogant and negligent consultants rather than no consultants. That’s a very worrying contention.

So it’s shit doctors or no doctors, so be careful what you wish for?

Righto.

Gross negligence should carry consequences thought shouldn’t it? I would say there was gross negligence in this case. Why would you think that was “lowering the bar” to tackle that? We don’t want dangerous practitioners do we?

Do you want to be looked after by the Consultant that cannot recognise the deteriorating patient? Do you want to be looked after by the Consultant who lets his dysfunctional relationships with colleagues affect his clinical decisions? This professor had “issues” with the PICU staff, looking down on them, thinking he knew better. Fuck that, people like that are dangerous. Why would you think that’s ok?

I don't have all the facts.

The situation described is clearly tragic. No one would want that to happen in their hospital.

The particular case was the first death of that diagnosis in that hospital, so apparently in that sense a one off. The coroner described the particular injury as "incredibly unlucky".

However, "the likelihood" was thought to be that she might well have survived it, if transferred to intensive case. And there appears to be an ongoing situation as you say with the relationship between staff etc.

There would need to be an investigation into all of that.

Without having more details about the actual events, it's difficult to say exactly what the hospital should be doing about it all. That's not to disrespect the mum's account at all, but the process involves setting all the accounts together. Some of that did happen at the inquest.

Of course what happened wasn't ok.

But it is not immediately clear that they need to strike off the doctor or doctors involved. Though, again, it is possible for that to happen.

The "This is going to hurt" series showed a doctor going through investigatory proceedings, that is how it would be done.

There can be changes and recommendations put in place instead of losing the consultant altogether, and if they are otherwise evidenced to be doing a useful job and are able to treat patients effectively, wouldn't that seem a reasonable option?

@herecomesthsun you're doing it again. “This is going to hurt” showed a doctor under immense pressure because of financial and other constraints. That is not what happened here.

You are being disrespectful because this family’s dreadful and tragic experience has been validated as being due to poor care and decisions. These are not wild and uncorroborated allegations.

Not sure if this link has been provided before..apologies if it has.

www.judiciary.uk/publications/jonathan-stevens-prevention-of-future-deaths-report/

Thanks @notimagain that is more or less the sort of recommendation from the coroner and response from the Trust that you would expect.

I am now going to hide this thread as I don't have anything more to add, and all the information is there.

Very very sad.

No, the real toxicity is the unquestioning belief that medical professionals are never wrong.

Like many other posters, we also lost a relative to the incompetence and arrogance of a consultant surgeon. Mysteriously, many medical notes seem to have been “lost” or altered completely from what the family know to have happened. The surgeon and his team tried to gaslight us at every opportunity into believing we were mistaken over what happened. We weren’t and we all know, if the surgeon hadn’t been such an arrogant prick our family member would have survived their illness and surgery, but instead they were left with such traumatic surgical injuries that the illness became untreatable and they were left to die a long, painful death.

This poor, young girl deserved better, more connected care, from professionals willing to question the hierarchy occasionally!

In my case, sepsis was taken seriously because I confused two items in my washbag while away on business and went to A&E fearing I might have poisoned myself, resting pulse was 130 and my temperature was through the roof. Similar symptoms weren't taken very seriously elsewhere.

Thank you for attaching the link. The response from the hospital is poorly written, shoddily formatted, contains at least one spelling error and uses in-house acronyms.

It is unsurprising that they have communications issues.

If the document were more than lip-service, the various teams required to sign-off business cases and agree documents could have met before the letter was written. Rather than:

'is due to be considered by the Trust's Investment Board in May 2022'
'this is due to be signed off in May 2022'
'It is anticipated that this will be completed by May 2022'

I wonder how much progress was made.

Should anyone find themself taking issue with KCH, this document shows the level of professionalism that the Trust is minded to apply when the stakes are high and the reputation of its highest paid staff are at stake.

This is such a heartbreaking read. Poor poor girl and her family.

I had no idea pancreas injury was a risk from bicycle handlebars (albeit a small risk). How can we prevent it from happening?

@Slippersue I had no idea pancreas injury was a risk from bicycle handlebars (albeit a small risk). How can we prevent it from happening?

You can't, unless you want to stop kids riding bikes.

Any blunt injury to the upper abdomen by falling heavily onto a blunt object could cause this. Fortunately it is rare.

I listened to Martha's mother on Woman's Hour today - it is just the most heartbreaking story. It made me cry again when she said that Martha was growing up to be a little feminist who would have loved to be on Woman's Hour celebrating her achievements and how sad it was that this was the way she got to be on there.

It is so incredibly strong of Merope to go public with their story in this way - it's made me think about the way I interact with medical professionals . She also has painted the most beautiful picture of Martha - you really get a sense of what a lovely girl she was and the immensity of their loss.

I read her piece in The Guardian a few weeks ago and it made me cry. The unbearable sequence of events, the arrogance of the consultant, the fact they were promoted soon afterwards.

In my opnion it was the arrogance of the Consultant that was the biggest single factor in that poor girl's death. Shame on him!!!😡

It's most heartbreaking piece I have read. Her mother writes so beautifully. But to be fair to the arrogant consultant, he wasn't being told the truth about how bad Martha's state was and that she had all the signs of sepsis. He probably would have come in or asked her to be moved to ICU if the junior doctor "Dr Blunder" had explained all her symptoms.

It was a horrific read. God, the ‘alternative scenarios’ her mum must torture herself with although obviously not AT ALL her fault. Poor Martha must have felt so, so unwell and frightened in her final days and hours. It makes me boiling mad to be honest, how on earth could they have missed this??

With Dr Bawa Garba (apologies if misspelt) there was a chain of failings that let to human error, but this was just pure arrogance and lack of concern. I hope all the doctors are demoted and forced to requalify for their grade, as well as answering under oath to an inquiry as to why they made the hopeless decisions that they did.

Poor Martha, rest in peace lovely girl.

Her mum is back in the news advocating for a 'Martha's Rule'- a campaign to give families and patients the right to a second assessment if they feel their concerns are not being taken seriously. Worth a read and she makes excellent points. It's here via the Guardian.

Absolutely tragic and sadly isn't the first nor will it be the last .