A baby died of sepsis after a London hospital initially discharged him without any antibiotics, leading to an urgent review of sepsis care at the hospital trust. Martyn Mirchev, who was just 11 months old, was rushed to Kingston Hospital by his parents on May 2, 2023 after he contracted a fever and began vomiting.
But the hospital staff sent the boy home just hours later, with no antibiotics and before any results from a throat swab had come back. But two weeks later, Martyn’s mum took him back to A&E after being referred by a GP who had become concerned by his fever, as well as a rash.
Martyn was assessed by a nurse and his heart rate was found to be too high, but staff weren’t able to check his blood pressure. According to lawyers Irwin Mitchell, who took on this case for Martyn’s family, the hospital nurse recorded Martyn’s condition as ‘normal’ on the Paedeatric Early Warn Score, which was incorrect.
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The computer system would have flagged to staff that Martyn needed a sepsis screening, but Martyn never had one. Therefore, instead of being referred to a senior doctor or nurse, he was transferred to the paediatric assessment unit, and again sepsis was missed during a second assessment.
It was only after another assessment by a registrar and concerns about Martyn’s rash that a sepsis screening was started – around two-and-a-half hours after he was admitted to hospital . But Martyn was deteriorating rapidly, and suffered a cardiac arrest. He died at around 5.45pm that day.
A serious incident investigation was carried out following the 11-month-old’s death, leading to a report which found that an urgent review into sepsis care and treatment in children was needed across the trust. Kingston Hospital NHS Foundation Trust has recommended a “deep dive” review in the paediatric emergency department.
In their examination of Martyn’s treatment, the report found that during an initial assessment, emergency staff failed to recognise and act on abnormal and incomplete observations. There was a delay in recognising and treating sepsis. Martyn should have remained in the emergency department and started ‘sepsis six’ treatment – a key set of medical interventions including intravenous antibiotics and fluids and to be started within an hour of suspected sepsis – the report added.
Instead, a decision was made to transfer him to a paediatric assessment unit around 40 minutes after he arrived at hospital. The investigation report also found previous cases had highlighted concerns regarding the identification and treatment of sepsis in children attending the emergency department.
Previous recommendations had “not been wholly effective in preventing” Martyn’s death, the report, dated November 2023, said.
Martyn’s parents, Veni and Deyan, aged 35 and 36, of Surbiton, Surrey, have spoken for the first time about their devastating loss.
Veni, Martyn’s mum, said: “After being sent home from hospital, Martyn didn’t seem his usual happy self and we remained concerned about him. When we heard nothing from the hospital about his swab we took him to the GP. When they told us to take Martyn to hospital we never imagined that in a few hours he would have passed away.
“That afternoon will remain with us forever and is something I don’t think our family will get over. Seeing Martyn as his condition deteriorated so quickly was awful. As his mum, all I wanted to do was care for him and help him, but I felt so powerless.
“Martyn was the most amazing little boy. His sisters adored him and it remains hard to think that he should still be at home with us all. He was just an absolute delight and didn’t deserve to die.”
His dad, Deyan, added: “It was hard enough to read the problems in Martyn’s care in the report. However, to see that there appears to have been previous incidents and that care issues were continuing is astonishing for all the wrong reasons.
“My heart immediately went out to others who may also be affected. We’re now left wondering how many other incidents have there been and are the other families even aware?
“While we want answers for our boy, we also want others who may be affected by similar care issues at the Hospital Trust to be aware and for improvements in care to be made. We wouldn’t want anyone to have face the hurt and pain our family are now left to live with.”
Signs of sepsis include slurred speech, confusion, extreme shivering and muscle pain, passing no urine in a day, severe breathlessness and mottled or discoloured skin.
For more information about sepsis visit the UK Sepsis Trust’s website.
A spokesperson from Kingston Hospital NHS Foundation Trust said: “We offer our sincere condolences to the family on the death of their son. Our investigation identified that there were problems with the care we provided and we are deeply sorry for these.
“We are committed to improving the care of children with sepsis. Immediate action has been taken to ensure the safety of patients and we recognise the importance of continuing to progress this vital work.”
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