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

Merope Mills writes near the start of the piece 'I am a fierce supporter of the principles of the NHS and realise how many excellent doctors are practising today. There’s no need for the usual political arguments: as the hospital in question has confirmed to me, what happened to Martha had nothing to do with insufficient resources or overstretched doctors and nurses; it had nothing to do with austerity or cuts, or a health service under strain.'

I fully support the NHS and abhor what the Tories are trying to do to it but that does not mean that doctors should be beyond criticism. Martha is dead because of the failings of the doctors in charge of her treatment. I applaud her mother for writing this article.

Yep, I know there was talk, on and off, of introducing some principles of aviation Crew Resource Management (CRM) into the medical world.

Whether it will ever gain widespread traction and acceptance in the medical world who knows but in aviation it became assessible skill and was subject to comment/assessment during recurrent training..which of course is maybe another subject for discussion.

bmjopen.bmj.com/content/9/2/e025247

It’s so hard but drs and nurses do know what they are talking about and they do see every day what the rest of us only experience in extremis but they hold our lives in their hands.

We have been told on numerous occasions by consultants, if we are not happy with the treatment DD is getting, to stand up and argue with junior doctors and nurses - to insist they get advice from on call consultants, and even if they tell us, there is no on call consultant; there is! They have totold us DD is safer at home with us than she is, in A & E in August and December and junior doctors do not understand cases like DD! It’s now in capital letters on her file to call the leading centre for advice on her.

Yes we’re lucky to have the NHS and a decent education system but there are inherent problems in both with hierarchy/authority overriding professionalism and accuracy. This awful situation highlights a professional elite culture which says an outsider can’t ask too many questions or show concern.

I’ve had mixed experiences with both professions and it does make me wary.

I’m guessing you’ve never had to watch your own child die whilst being treated as a Cassandra figure?

Are you saying that we should accept this sort of medical negligence out of gratitude that we do have an NHS, so that the poor people will have any sort of health care?!

Surely we can be grateful for having the NHS, whilst at the same time expecting that standards of care are met, and being able to complain when they are not.

We don't need to be grateful for every crumb, out of fear of having nothing if we complain or want more.

I don't want the NHS privatised either, but even in the worst case scenario and some sort of private insurance was introduced, it doesn't mean that we can't also make provision for those unable to afford it - look at how many other countries manage to do this. The US system is not the only one available. People have been so conditioned to think that 'no health care for the poor' is the only alternative to the NHS that we can't make any criticisms of it, in case that's the end. But we can and should expect a system that works well for basic standards of care, and it is right to complain when it does not - particularly in a case like this, where it is not further resources, money, staffing or anythingn that is needed, but a change of culture and attitudes.

The point about clever people being funnelled into medicine is a really good one. You can be very very smart but totally lacking in common sense and compassion. You can be very clever but also lazy. I've seen a case where a man died because the doctor responsible for his care couldn't be bothered to walk down a corridor and actually see him. I've never forgotten it.

God, what a harrowing read, that poor child and her family.

I’ve been hospitalised twice due to GPs telling me to take incorrect medication for my very, very common medical condition.
The NHS legal teams are not what I’d describe as humans. I had to attend an inquest where the NHS lawyer successfully argued to keep a key employee from being questioned and written NHS evidence from being presented. I believe some keys notes had also “disappeared”

Ive never understood the weird judgemental attitude of drs either —- a consultant writes to GP “ I saw Ms D in clinic today, a pleasant 59 year old woman…… “ what the fuck has me being pleasant or unpleasant got to do with it??

It's a heartbreaking story.

I thought that they had introduced checklists etc and an attitude of listening to others, instead of 'God syndrome' - following mistakes and arrogance. Just as in cockpits when mistakes happened.

Of course, they will say that we will learn from our mistakes...

Also people seem to forget that the consultants in private practice are… the same consultants as the ones treating you in the NHS. Literally the same people. Prof Checked Shirt probably has a private practice where he behaves the same and the fact you’re paying him through insurance is no guarantee he won’t mess up there too.
Where I worked in the private healthcare sector there wasn’t a single medical doctor/surgeon under NHS retirement age who didn’t have both NHS and private practices. The private sector seems to heavily rely on doctors maintaining their competencies through their continued contact with the NHS. This is a wider healthcare issue not something that can be assumed to be better in the private sector.

I have a friend in aviation, and I previously showed a similar article to her about a case of medical negligence where a junior nurse spoke up and questioned a senior consultant, and in that case saved a life. But the junior nurse nearly didn't challenge it because she was afraid to do so. The point of the article, which I raised with my friend was that this hierarchy of arrogant 'experts' could be dangerous in her profession too.

She reassured me that the CRM system that they use in aviation is designed to stop this from happening. They encourage people to question things, and go through constant training so there is no 'pilot knows best' attitude any more.

I agree - the medical profession could benefit from that sort of process

Reading this in a hospital where DH is

I agree googling everything and asking asking asking questions is key

Thanks for sharing Op - heartbreaking. I'm one who very much would defer to the medical professionals but reading this, I'll definitely be challenging should I need to.

I've just cried my eyes out reading this, honestly it was such a devastating story and told so eloquently by her mother. Rest in peace Martha.

My friend was recently in intensive care with sepsis following an infection and it was terrifying but he was in the right place and they tried everything for him. It was touch and go for a while but he has made almost a complete recovery. It breaks my heart that this could have been the case for Martha.

This is a awful read poor Martha’s family,
my DS was very unwell at the beginning of this year he was fobbed off and lied to by the GP for weeks it took me to insist I attend an appointment with him he’s 20 and Covid restrictions I wasn’t supposed to he was referred to the hospital.
I went with him to that appointment The consultant took one look at him and he was admitted there and then and was in theatre within 4 hours.
his colon almost ruptured he’s now got a stoma bag for life. Some doctors and medical professionals really think they are above themselves

Unbelievably sad and tragic that every facility was there at their disposal to save her.

Agree also that while of course patients are looked after and A and E is 24/7, a lot of the NHS seems to operate conventional office hours. We found out when MIL was extremely unwell on Easter weekend

This is heart-breaking. The arrogance of so many doctors is frightening.

As someone with chronic illness I know you have to to your own research and advocate strongly for yourself to receive adequate healthcare.

Before becoming ill, I would also have "trusted the doctors". I now know you can't. It shouldn't be like that. You shouldn't have to fight and argue and challenge and look up your own information. And as we've seen here the consequences can be catastrophic.

I've just read it and it's absolutely heartbreaking. I can't imagine what they must be going through as a family.

@Thisdoesnotendwell I’m a midwife and had a similar experience, although I was qualified at the time and it still made no difference.

The labouring woman was showing worrying signs, had a heavy vaginal bleed while labouring, was in uncontrollable pain despite massive amounts of analgesia, was vomiting profusely and felt very unwell. The CTG was normal, baby totally unaffected, and so no matter how many times I called the registrar and said I was concerned I was told how the CTG was “beautiful” and to relax.

I did as my training told me and escalated higher, I asked the consultant to review. It took 4 phone calls and 1 hour before the consultant agreed to come and review the patient. I was dismissed as being a “junior midwife” in this time.

The consultant came, didn’t speak to the woman, didn’t read the notes, took one look at the CTG and left. My concerns were not about the CTG but the view was the CTG is fine so no concerns.

I wasn’t happy but I was powerless. The buck stops with the consultant so what do I do now. I started questioning myself, am I worrying over nothing. If the very experienced consultant isn’t worried maybe he’s right.

The woman continued having gushes of blood each time she changed position and struggling massively. I continued informing the consultant every single time but he never came to see the patient again. Eventually she had a very large bleed, far more than previously and the fetal heart rate plummeted. I pulled the emergency buzzer. She was rushed into theatre and had a Caesarean section where it was confirmed she had suffered a placental abruption.

Now in this case thankfully mum and baby were fine and survived. But it could have been so so different. This lady had been abrupting slowly for hours but no-one cared until it became life threatening. No-one intervened early and waited until it could have easily been too late. The consultant said to the lady how lucky she was that we acted so quickly when the baby was struggling and the lady was so so thankful for that. But we didn’t act quickly. We let a worrying situation develop until it became life threatening and we were simply lucky that both survived.

8 years ago this week my 13 year old had sepsis. Today he ks playing in a rugby match, going for drinks with friends and preparing to return to Uni.

He deteriorated from a healthy happy child who set off to school that morning to a critically I’ll one by 4.30pm.

I will be eternally grateful to the triage nurse who took his blood pressure and had him in resus with 6 doctors attending within 5 minutes.

She saved his life.

I don’t normally cry when I read stories like this but I have tears pouring down my face right now. What a heartbreaking and devastating story. I just don’t have the words but I hope that Merope Mills’ report helps another child somewhere.

Martha 💐

I read it this morning and cried at the part where poor Martha slipped away with her mother repeating "I love you". The sense of impotent terror is palpable through the whole piece.

I have had poor medical care and know the awful fear of trying to get someone to just understand and take you seriously- but nothing like this. What could compare to losing your child in this way? My heart goes out to her and the whole family.

I fully agree with the poster above.
Its truly heartbreaking.

She reassured me that the CRM system that they use in aviation is designed to stop this from happening. They encourage people to question things, and go through constant training so there is no 'pilot knows best' attitude any more.

I'd just gently rephrase that as "there's no pilot automatically knows best anymore" ..

As I recall it the idea in aviation, when this concept was introduced, was to ensure pilots (especially some captains) were open to input/invited input/generated an open atmosphere at work ... However It wasn't designed to give everybody on the crew an equal vote or say in what to do next, simply because not everybody has the same level of expertise or experience.

If we drag this back into the medical context I guess the parallel would be is a consultant open to listening to input from colleagues/other advocating for the patient? does he/she welcome and encourage input from others on the team and does he/she accept there might be times when team members have to act quickly and off their own volition if time is short, and if they do so they will face no sanctions for doing so.

The thing I can't understand above all is why there was such reluctance to move her to the PICU when there was a bed available. If a child is seriously unwell and not improving why would you not get the PICU staff to do an assessment even just as a precaution. Cost?

I read it this morning. It made me cry. What a heartbreaking, appalling outcome.