A 13-year-old girl who died after catching sepsis at King’s College Hospital could have survived if doctors had spotted early warning signs and sent her to intensive care earlier, a coroner’s inquest has found.
Martha Poppy Mills was transferred to King’s after sustaining an injury from falling off her bicycle, while on a family holiday in Wales last year.
She died on 31 August 2021 at the centre in Denmark Hill aged just thirteen.
An inquest at St Pancras Coroners Court, north London, revealed that hospital staff missed multiple opportunities to save the young girl’s life, despite her deteriorating condition.
“Whilst at King’s, Martha was not referred to the paediatric intensivists promptly,” read the coroner’s report. “If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries.”
It added that Martha’s care “fell down” between paediatric departments at the hospital and was hampered by a substandard paper-based early warning system.
Martha, who was described by her parents as “bright, healthy, and enthusiastic”, was the first-ever child to die at King’s with a pancreatic injury. Her causes of death named by the coroner were sepsis, abdominal trauma, refractory shock and pancreatic transection.
In an emotional witness statement to the coroner, Martha’s mother said that, after their daughter contracted sepsis in August last year, she and her husband raised concerns about Martha’s deteriorating health to doctors several times, yet they did not escalate her care.
Her initial symptoms included high temperature, diarrhoea and low blood pressure. Days later Martha’s mother raised the alarm again after she began to bleed heavily through a tube inserted into her arm and later developed a high fever, low blood pressure, heightened heartbeat and rash on 29 August.
It was not until the following day that Martha was taken to intensive care.
The coroner’s report, which was published on 28 February, said that “action should be taken to prevent future deaths” and that King’s had “the power to take such action.” They raised concerns that there is a risk of “future deaths” unless action was taken by the hospital.
Actions proposed by the coroner to avoid similar tragedies were that King’s replaced their paper-based bedside paediatric early warning score with electronic recording, and that there should be greater cooperation between paediatric intensive care and other departments in the hospital.
The coroner’s investigation into Martha’s death began on September 2021 and finished last month (February). The final report was sent to Martha’s parents and the Care Quality Commission England, a watchdog organisation monitoring healthcare facilities across the country.
Professor Nicola Ranger, chief nurse at King’s, said: “We would like to extend our deepest sympathies once again to Martha’s family for their loss.
“We accept the Coroner’s findings, and on behalf of the Trust, I would like to apologise for the failure to recognise Martha’s deteriorating condition earlier, which led to delays in providing appropriate treatment. We are committed to delivering further improvements to the care we provide to patients at King’s.”
King’s has been given until 25 April 2022 to respond to the coroner’s findings. Their response must outline what actions they are going to take, have taken and offer a proposed timeline.