Martha Mills died after being admitted to the hospital with an injury to her pancreas after falling off her bike on a family holiday. Her mother Merope described the injury – whereby the force of the fall pushed her pancreas against her spine, causing a laceration - as a 'difficult, tricky injury', but one that should not have been fatal.
While Martha was in hospital, she developed an infection that turned into sepsis. Her parents frequently voiced their concerns to medical staff that Martha's condition was deteriorating very quickly but their appeals were not listened. Martha was eventually moved to the ICU but by then it was too late to save her life.
A subsequent inquest and medical review into her death concluded Martha's sepsis was not managed properly, particularly that she was not transferred to intensive care quickly enough to support her organs as they became overwhelmed.
The coroner concluded that had she been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries.
The hospital trust admitted that mistakes were made and apologised to the family.
Merope said that as her daughter's condition started to worsen, their concerns were not taken seriously and staff repeatedly reassured them Martha was fine. Merope is calling for Martha's rule to be introduced into hospital policy to 'formalise the idea of asking for a second opinion, from a different team outside the team currently looking after you if you feel you are not being listened to'.
She added that asking for a second opinion 'shouldn't be a problem' and shouldn't involve confrontation.
A similar system already exists at the Royal Berkshire Hospital where people can call a critical care hotline for immediate help.
Although one response is that such a system could be overrun, reviews have shown that when the Royal Berkshire NHS Trust first trialled the system, it received just 37 calls in the first year, some of which resulted in crucial interventions.
Sepsis presents a major challenge to medics not least because patients tend to deteriorate very quickly – with symptoms often being noticed first by family since they involve the patient becoming disorientated and unlike themselves. Sepsis guidelines contain advice to medics specifically to 'Pay particular attention to concerns expressed by the person and their family or cares, for example, changes to usual behaviour'.
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