A senior doctor should have referred a teenager to intensive care when she displayed several “high-risk indicators” of sepsis days before she died, a medical tribunal has found.
Martha Mills, 13, had been an inpatient on the Rays of Sunshine Ward at King’s College Hospital in London after she suffered a serious injury to her pancreas when she slipped while riding a bike on a family holiday in Wales in July 2021.
Martha collapsed on August 30 and was moved to intensive care, before she was transferred to London’s Great Ormond Street Hospital, where she died in the early hours of August 31. At a 2022 inquest into her death a coroner ruled Martha would most likely have survived if doctors had identified the warning signs and transferred her to intensive care earlier.
Martha’s mother, Merope Mills, an editor at The Guardian, said she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times but these were not acted on.
The couple later successfully campaigned for Martha’s Rule to give patients, families and carers the chance to easily request a second opinion from a senior doctor in the same hospital in the event of a suspected deterioration or serious concern.
In a Medical Practitioners Tribunal Service (MPTS) about what happened, the panel heard that Martha had experienced a fever, increased heart rate and had a catheter inserted into her vein, which was “ultimately considered” to be a likely source of the infection that led to her death from sepsis.
More spikes in her temperature followed, before consultant hepatologist Professor Richard Thompson saw Martha on his morning ward round on Sunday August 29 at the hospital, one of three locations in the UK which specialise in the treatment of paediatric pancreatic injuries.
The on-call consultant left the hospital at 3pm, but was phoned at home two hours later by a trainee doctor, who gave an update on Martha’s condition.
Medical records showed she had deteriorated over the course of the afternoon, and into the early evening, with a drop in her blood pressure, the appearance of a new rash and increases in heart rate, respiratory rate and body temperature.
Tribunal chairman Robin Ince noted that by 5pm there were “several high-risk indicators” as set out in the Nice guidelines relating to sepsis.
He said: “These changes collectively indicated a sudden and significant deterioration for no clearly identified reason…it was evident that by around 5pm the clinical condition of Martha justified escalation to PICU (paediatric intensive care unit) and this opportunity was not taken.”
The duty registrar called Prof Thompson again at 8.30pm because of ongoing concerns over Martha’s fever, but she was kept on the ward despite the continued presence of moderate to high-risk indicators and the absence of meaningful clinical improvement, said the tribunal.
Mr Ince said: “The tribunal notes that Professor Thompson expressed a preference to prearrange any PICU involvement, rather than having PICU clinicians arrive unexpectedly and cause distress to Martha’s parents.
“While the tribunal understands the desire to manage the family anxiety sensitively, this did not, in its view, justify withholding or delaying a clinically indicated escalation of care.”
He added: “The tribunal therefore concluded that the GMC (General Medical Council) has proved its case that Professor Thompson failed to take more aggressive intervention from 12 noon onwards in that he did not escalate Martha to the PICU team for a direct clinical review.”
The tribunal also ruled that Prof Thompson should have conducted a direct in-person review and assessment of Martha, including the developing rash, from 5pm, which would have been “beneficial”.
Mr Ince said: “He would no doubt have discovered that no observations had been taken in respect of Martha from 2pm to at least 4.45pm. The tribunal notes that one of the advantages of escalating a patient to PICU would have been an increased level of monitoring.
“Although no explanation has been given to the tribunal for the failure to monitor Martha between 2pm and 4.45pm, this absence of monitoring on the ward would no doubt have been a significant factor in justifying such an escalation.”
The tribunal cleared Prof Thompson of the GMC’s allegations that he gave “outdated, misleading” information on Martha’s condition to a consultant colleague in the intensive care unit, and that he failed to mention her rash.
The MPTS hearing in Manchester continues as the tribunal considers whether Prof Thompson’s fitness to practise is impaired.
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