King’s College Hospital staff failed to move teenager to intensive care soon enough – and she died

By Robert Firth, local democracy reporter

A girl who died after a cycling accident on a family holiday could have been saved if a South London hospital had treated her properly, a coroner has found.

Staff at King’s College Hospital in Lambeth delayed sending Martha Mills to children’s intensive care doctors, despite contracting sepsis and her condition deteriorating.

The 13 year old was sent to the hospital after suffering an injury from her bike handlebars while cycling on a family break in Wales last year.

She died at the major trauma centre in Denmark Hill a month later in August 2021. King’s College Hospital has apologised to Miss Mills’s family and said it is improving care.

Senior coroner for Inner North London, Mary Hassell, issued a Prevention of Future Deaths report following the inquest into Martha Mills’s death. Coroners produce the documents when they believe more people could die in the future unless changes are made by an organisation or individuals.

The report, dated February 28, reads: “Whilst at King’s Martha was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries.”

The document also says Miss Mills’s care fell down between being treated by children’s liver doctors and intensive care staff. It reads: “The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists. I heard evidence that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments.”

But the report goes on to say that efforts to improve the relationship between the two hospital departments stalled due to the pandemic. It says an early warning system used to identify early signs of deterioration in children patients is still paper based at the hospital – despite the adult system being electronic.

Martha from London, described by her parents as “bright, healthy, enthusiastic”, was the first ever child to die at King’s College hospital (KCH) with her type of pancreatic injury. She was transferred to the South London hospital because it is one of three national centres for the care of children with pancreatic trauma.

Her mother, Merope, the editor of the Guardian’s Saturday magazine, told the Guardian she was “a fun, singular, very intelligent girl, who had such an appetite for life and all its opportunities. She was growing up to be a strong, remarkable woman … We have now had confirmed what we always knew – that this was a preventable death. Martha’s future has been stolen. We feel outraged on her behalf.”

Prof William Bernal, who produced a serious incident report on Martha’s death for KCH, said there were at least five occasions when she should have had a critical care review.

He wrote that Martha’s chances of survival “would have been greatly increased” if she had been admitted to critical care earlier.

By the time of Martha’s transfer to paediatric intensive care on 30 August she had septic shock and was “profoundly unwell … and failed to respond to interventions”.

Bernal added: “It was reported that referrals were made more often and with a lower trigger threshold, and that relations were easier, with the general rather than liver paediatric services. The perception reported was that the liver ward team sometimes questioned the value of review.”

The inquest heard that KCH was making changes in the wake of Martha’s death, including improving diagnostics and taking account of parents’ views.

Medical staff told the coroner that until the childhood early warning system is digitalised, care of children at the hospital will be substandard.

The report reads: “It was put to me very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal, with a higher risk of this sort of situation recurring.”

The Prevention of Future Deaths report was sent to Miss Mills’s parents, England’s Care and Quality Commission – an organisation that inspects hospitals – and the chief coroner of England and Wales.

Professor Nicola Ranger, chief nurse at King’s College Hospital NHS Foundation Trust, 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.”