When Doctors Don’t Listen to Patients | The Tragic Case of Martha Mills

After a bike accident while on vacation, 13 year old Martha Mills was soon admitted to the hospital with a serious pancreatic injury. Her condition was fully treatable, but after her care team refused to listen to the concerns of her family, Martha would go through days of suffering septic shock before passing away. It was only after her passing when NHS hospitals would implement Martha’s Rule, a rule giving patients and families the legal right to a second opinion.

I’m Petal Palmer and I bring you stories of medical cases and mysteries from around the world.

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SOURCES:
https://www.theguardian.com/society/2023/sep/13/theresa-may-backs-campaign-for-marthas-rule-of-second-medical-opinion
https://www.theguardian.com/politics/2023/sep/14/marthas-rule-what-it-will-mean-for-patients-and-their-families.
https://www.theguardian.com/society/2024/feb/21/marthas-rule-granting-urgent-second-opinion-to-be-adopted-in-100-english-hospitals.
https://www.judiciary.uk/prevention-of-future-death-reports/jonathan-stevens-prevention-of-future-deaths-report/.
https://www.judiciary.uk/prevention-of-future-death-reports/riya-hirani-prevention-of-future-deaths-report/.
https://www.theguardian.com/society/2023/sep/14/government-backs-marthas-rule-on-second-medical-opinion-in-england.
https://www.gov.uk/bank-holidays.
https://www.myhsn.co.uk/top-tip/what-is-a-junior-doctor [Accessed 7 Mar. 2024].
https://www.theguardian.com/lifeandstyle/2022/sep/03/13-year-old-daughter-dead-in-five-weeks-hospital-mistakes [Accessed 5 Mar. 2024].
https://evidence.nihr.ac.uk/alert/communication-problems-are-top-of-patients-concerns-about-hospital-care/ [Accessed 5 Mar. 2024].
https://www.nhs.uk/conditions/sepsis/.
https://www.england.nhs.uk/get-involved/cyp/pews/.
https://www.england.nhs.uk/publication/national-pews-observation-and-escalation-charts/.
https://www.theguardian.com/society/2022/mar/04/girl-13-likely-to-have-survived-if-moved-to-intensive-care-coroner-rules.
https://hansard.parliament.uk/commons/2024-02-21/debates/24022125000011/MarthaSRule
https://www.bbc.co.uk/sounds/play/p0gbjmv5 [Accessed 5 Mar. 2024].
https://www.england.nhs.uk/patient-safety/marthas-rule/#:~:text=This%20is%20Martha

Music from #Uppbeat (free for Creators!):
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TIMESTAMPS:
00:00 – Introduction
05:31 – Bike accident
08:37 – Bronglais hospital diagnosis
10:44 – King’s college hospital
16:09 – BedsidePEWS
28:50 – Septic shock / ICU
33:45 – Investigation
37:30 – Martha’s Rule

Disclaimer: I’m not a medical professional and nothing in this video is meant to be taken as medical advice. If you’re experiencing any health issues, speak with your physician.

#truecrime #medicalmalpractice #medicalnegligence

Martha’s law Martha’s rule Martha’s rule with Martha’s rule we want to formalize and codify a way for people who are worried or worried about deterioration effectively formalizing a second opinion within a hospital if you’re worried if you think something’s going wrong you should Scream the war down because

That’s what I didn’t do and I you know regret it I will regret it for the for the rest of my days but but the very existence of Martha’s rule says you don’t need to scream the ward down what you need to do is call this number cuz you got Martha as

Well today we’ll be discussing the case of Martha Mills Martha was a bright healthy young girl and was truly just going about life as any person her age would she spent lots of time with her friends and she always enjoyed a vacation with her family that was until

One accident quickly turned her summer holiday from being a fun trip with her family into an extended stay in the hospital while diagnosed with a serious injury Martha and her family knew that they would have a relatively long but doable journey to recovery Martha’s condition was fully treatable however things took a tragic

Turn when Martha’s care team failed to acknowledge and treat the serious deterioration that was occurring in her body and this neglect she received at the hospital was so bad they created a lot to avoid this outcome from happening to someone else but just to introduce myself my name is pedal Palmer and on

This channel I post anything involving medical Mysteries and crime if that is something that sounds interesting to you please consider subscribing if you end up liking this video all right let’s get into this case Martha Mills was born on September 4th 2007 to parents Marie Mills and Paul lady she was described by

Her mother as being busy with life she said how she enjoyed meeting with her friends in the park she would make funny little videos on her phone and she’d played games like Kiss Mary kill like any other child her age a school of Martha had expressed quote for me there

Were two sides to Martha the person who danced with me on the train platform the one who had fun sassy arguments in American accents with me the one who would put a PE bag on her back and call herself a turtle then there was the one

Who quietly sang while I rested on her shoulder on the train home she would always be there for me and I would be there for her too it was said that she loved reading she enjoyed writing her own stories and she enjoyed playing Minecraft with her friends her mother

Described how she had the most contagious laugh how she played the cello and enjoyed writing her own songs and books she also described how Martha had many hopes for the future she said how she would often wonder aloud if she’d become an author an engineer or a film director very different fields but

She had so many interests and was very open about the many Endeavors she planned on possibly pursuing when she was older Martha was an older sister to sister lahi and she and her family were described as being really close often enjoyed traveling together on trips and her mother marpie described that the

Summer of 2021 was no different that summer the family had planned a trip to Wales they actually booked a cottage near a place called iriri National Park which is also known as snowdonia while snowdonia is a common name used for the park I’ll be referring to it as its

Welsh name which is ireri and this park is wales’s largest national park it’s highlighted with Landscapes of large mountains lakes trails and many people come here annually to enjoy hike at this park the area is commonly visited during the warmer months by many people hoping to get outdoors and just enjoyed the

Scenery so it was no surprise that the Mills Family planned and book their trip to come here that summer for the trip Marie had booked a cottage on the outskirts of irie Park she described it as being a small old farmhouse with low slung beams and no Wi-Fi or phone

Reception parking was at the bottom of a hill So based on this having no Wi-Fi or phone reception it was clear they were going to be there to enjoy their time in nature at Airi there was a beach called barmouth Beach it’s a really beautiful beach it’s surrounded by the Irish Sea

And the family of four enjoyed spending their time there while on this trip on the first day of their trip was very sunny it was warm and on that day the family had gone bodyboarding at the beach and after they went bodyboarding they headed back to their Cottage where

Martha and her mother painted the Valley View and in the evening they simply had dinner at a pub they played card games and they spent time with one another on that second day the family had decided to rent bikes to enjoy a ride along a bike trail that led them to the beach

This bike path was a popular 9M out and back to the beach and it was described on a guide to the area as Scenic flat and familyfriendly nothing would have raised serious red flags about this Trail plus Martha’s mother described her as being a very cautious child she was aware of her

Surroundings and they even jokingly referred to her as Captain sensible just to do to how mindful she was so on that second day when the family headed down to the beach on their bikes Martha rode alongside her mother and the family spent the afternoon enjoying a Leisure

Time swimming in the water eating some food and just enjoying the warm weather after some time at the beach they eventually decided to head back to their Cottage and together of course they were going to be heading back on the same bike trail they took to get to the beach

By that point in the day the bike trail was relatively busy it was a well-known Trail and there were other families heading to the beach heading to their Cottage or just going for a bike ride as well now with this Trail being close to the Sea like any other location that is

The area was relatively windy and so because of this some sand from the beach had blown onto different patches of the bike path and these patches of course made the trail a bit more slippery to ride on so when the family was riding back they were being cautious and

Cycling slowly to a avoid bumping into any other cyclist and B avoid skating from the sand on the trail they were doing fine the ride went well for a while until suddenly Martha ended up slipping on a patch of sand that had blown onto the trail and she fell on top

Of her bike as soon as she felt Martha had quickly crawled her way over to the edge of the trail to move out of the way of the other cyclists and she was not feeling great her mother described that she was making what sounded like zombie sounds of someone badly winded and so

The family stayed off to the side waiting for her to recover but Martha wasn’t just badly wounded she was in a lot of pain because this wasn’t just a skid and a fall but because when she fell on top of her bike one of the handlebars had rammed into her abdomen

And this caused so much pain she was unable to get up from the ground for several minutes eventually her family was able to get her back to the cottage but with how Martha was looking and feeling they were growing more and more concerned along the way so much so that

Evening they decided to bring her to a local minor injury unit to get checked out and make sure everything was okay when they arrived at the minor injury unit Martha and her family were greeted by a nurse who would be doing an examination of her injury and when

Martha raised up her t-shirt for the nurse to get a closer look they noticed that there was an o-shaped mark on Martha’s abdomen and this Mark was a perfect match in size to The Handlebar of the bike that she had fallen on there was no blood there was

No Cuts just a red o-shaped mark because of the concern with this injury the nurse had called a doctor on the phone and described the situation and had requested for the doctor to come check Martha out and speak with the family however the doctor didn’t think too much

Of the situation and just told the nurse hey I don’t think I need to see her she probably just has some internal bruising I’m just going to prescribe her some paracetamol and everything should be just fine so the doctor wrote them the prescription and they were sent off

Hoping that the paracetamol would do the trick once the family had arrived back at their Cottage they headed to bed likely hoping that some sleep might help Martha feel a bit better however Martha struggled to sleep that night her abdomen just kept erupting in pain and

It was by 2:00 a.m. when her family had taken her to a local accident in emergency room or an A&E for proper re-evaluation at that time any type of movement was agonizing for Martha so the family had carefully placed her in one of the wheelbarrows provided at the

Cottage her father Paul wheeled her down and they gently placed her into the car to head to the Bron glaz Hospital located in abber Ritz withth Wales when they arrived at the hospital in the middle of the night the team of the hospital had examined Martha they agreed

To run some tests and they admitted her to stay overnight for further observation not only this but this time she was actually evaluated by a physician to oversee her care and after a few hours had gone by right around Sunrise a doctor had come into Martha’s

Room and with what was described as a serious expression this doctor told them hey we have reason to believe Martha has pancreatic trauma in the article regarding the incident marpie described quote she had fallen with such force that her pancreas had been pushed against her spine causing El aceration

By that point the family’s concerns were finally confirmed they knew Martha was dealing with a serious injury but despite being very worried they had full faith in the National Health Service or NHS system to provide for them at the time of this case England was just

Coming off of the tail end of the covid-19 lockdown and because of this there was an uproar of love and support for healthcare workers and the overall institutions within the UK at the time many people had signs in their windows or they had chalk drawings out front of

Their homes just to voice support of and thanks for the NHS and their workers most commonly seen were signs featuring rainbows and proclamations of adoration Martha and lah even made their own signs painting rainbows and writing the words thank you to place at their window Marie

Even described how for a few weeks on every Thursday the family joined in on the communal clapping with Martha banging a pan with a wooden spoon to show their support when recalling her worries and fear regarding the situation marpie stated I was frantic but one of

The doctors grip me by my shoulders it’s going to be a tricky couple of days but she’ll be fine they knew they were working with the good team who’d ensure that Martha got better and they were confident in her recovery this would be just another time for Martha to look

Back on and tell the story of the journey she went through during summer vacation after a bike mishap Martha was eventually air transferred via helicopter from the University Hospital of Wales in Cardiff Wales to King’s College Hospital in London England this transfer was made because located within

King’s College was one of the three specialist centers in England which looked after children with pancreatic injuries Martha was placed in the raay of sunshines Ward which was a pediatric Ward for longer term stays and a nurse had described to the family that this was a really good Ward to be on they

Explained how the ward was well funded due to the combined donations of money to the NHS and fees of private International patients the family was very optimistic that they would be able to recount the story as an unfortunate summertime mishap marpie even began documenting pictures of Martha’s hospitalization with her camera due to

The confidence they had in her recovery this of course without knowing that she was taking some of the final images of Martha during her first two weeks things were looking as if they’d be okay marpie and Paul would alternate staying with Martha each night Martha was able to

Walk the halls with some help and her friends were able to visit and support her and she seemingly was recovering they decorated her room with pictures she liked and they’d gotten into a routin of when the nurses would come in when Martha would get lab work and just

Overall normal things for a stay in the hospital the family was constantly reassured that they were in the best place and that and they were extremely thankful for that unfortunately though this period did not last Martha began to rapidly deteriorate after a surgery that she received I wasn’t able to find many

Details regarding the surgery however it’s implied in two of the Guardian articles that the surgery was intended to Simply sort out the laceration and check for more damage during the weekend of the 21st to 22nd of August Martha had developed a fever and she was not feeling well she was shivering in her

Bed she had constant diarrhea and she would wretch feeling as though she had to throw up it was clear she was showing signs of infection and because of this doctors prescribed her antibiotics and told them that within 72 hours the infection should be gone and Martha shouldn’t have a fever anymore

However 72 hours had gone by and Martha did still have a fever in fact she now had even more concerning symptoms as well Martha had a line in both her arm and in her abdomen and on that Wednesday she began be bleeding profusely from both sides the blood had seeped through

Her bandages and soaked both her pajamas and her bed sheets at the time doctors just explained how this was all a normal side effect of an infection how her clotting abilities were slightly off thus it’s all normal that she was bleeding so to treat this the doctors gave Marther lots of clotting products

And fortunately after 2 days the bleeding had stopped on that Friday morning but things were still not looking up for Martha she still had a high fever it was so debilitating she was unable to enjoy the many forms of entertainment she had whether it be a

Book a movie or playing games the fever was so bad she had no interest in doing anything she would regularly enjoy and this was concerning for the family as doctors were unable to pinpoint the source of Martha’s infection even more troubling was the fact that the next day

Was going to be the start of the weekend which was concerning because on the weekends things tended to be very quiet in the ward as consultants would typically go home after rounding and would only be available on call afterwards and it didn’t help that this weekend in particular there was a bank

Holiday a bank holiday weekend is a national longer 3-day weekend in which Monday was also considered an off day and this meant that the ward would not only be less staffed than usual but that they would be less staffed for a longer period of time the summer bank holiday

Was on the 30th of August and it was making Martha’s family incredibly worried doctors were still telling the family that they weren’t sure that what was causing the infection so the idea that less staff would be present for 3 days straight while Martha’s Health was deteriorating was terrifying for them

Marpe knew that if she wanted to have Martha seriously looked at that that Friday was a day it needed to happen and despite the lack of information from the doctors marpie and Paul were connecting the dots between Martha’s condition and septic shock that’s when marpie approached the consultant for the day

And blatantly told them quote I’m worried Martha is going to go into septic shock on a bank holiday weekend and none of you will be here however the consultant looked over his screen in front of her before dismissing the idea of septic shock telling her I’m not

Worried about sepsis it’s just a normal infection the next day Saturday the 28th Paul had been reassured Again by the head of the consultant team that infections were expected to come and go with the sort of injury Martha had but later that same day Martha developed a new

Symptom dizziness S standing so he notified the Consultants about this new symptom however they didn’t seem too concerned about the new symptom appearing alongside the persisting fever in England the NHS has several systems of rating and ranking patients in terms of need symptom severity and other Healthcare metrics that Aid them in

Prioritizing the care of more critical patients one of these systems is called the bedside pediatric early warning score known as bedside pews or simply pews this system was implemented in 2018 and it is meant to help new doctors in the cases of child patients know instantly what state a child is in

Before even seeing them however this rating system as many are is flawed and often overlooked but side pews uses numbers to assign categories of need or criticality to patients with several different charts for different age groups and these are the age groups 0 to

11 months 1 to 4 years 5 to 12 years and 13 plus years old as seen in the preview screenshot of a bedside Pew scale for Martha’s age group the document is rather cluttered and difficult to understand at a mirror glance starting at the top of the page the document

Features slots for basic patient information details of the alarm limits and additional notable risk factors of the patient alarm limits are just the upper and lower boundaries for metrics such as heart rate blood pressure and many more and these will sound alarm to alert staff to address IC change in the

Patient vitals the bulk of the document is taken up by dozens or rows of boxes for taking vitals and other metrics categorized into Airway and breathing circulation and disability and exposure the bottom section describes the ranks in their Associated numbers so that working Physicians can reference them when determining where to rank the

Patient on this scale the ranks and numbers are as follows there’s low l or score 124 where staff have concerns and feel the patient needs more monitoring at this rank medical review timings or response time is to be decided by the medical team there’s medium m or score 5

To6 where there’s a new suspicion of substance and Staff feel that a more advanced Medical review is needed at this rank medical review timings are within 30 minutes there’s High H or score 9 to 12 where there’s a new suspicion of septic shock and Staff feel

That a rapid review is needed at this rank medical review timings are within 15 minutes and finally emergency e or score 13 plus where the patient is responsive only to pain unresponsive or have an abnormal pupilary response and Staff feel that emergency review is needed for life-threatening situations

At this rank there’s an immediate review but as you can see the paper clearly is clunky and not easy to see which obviously can’t be helpful to the doctors the way that it’s claimed to be on that Wednesday afternoon Martha was listed at being a six on the bedside Pew

Scale this meant that the doctors who designed that score either felt that more intensive monitoring was needed generally or that they knew she’d developed sepsis as they later found out the care team danced around the word sepsis but marpie and Paul both stated that they knew the doctors were aware

But were playing it down it was then known that Martha needed to be moved to the piku due to these symptoms however she was not marpie noted that the piku was not overloaded at that time and had several available beds but the carers in charge at that time didn’t feel the the

Need to move her this is one of the many things that led to Martha’s increased Decline and eventual passing on Sunday the 29th there were some changes in the demeanor of some members of the staff overing Martha’s care a consultant that marip referred to as Prof checkshirt for

Anonymity spoke to the surgeon outside of Martha’s room in hush tones during rounds despite Marie’s choice to keep his name anonymous Prof check shirt’s real name was revealed to be Prof Richard Thompson in another article via the guardian Prof Richard Thompson was said to be an Oxford educated man who

Was in his late 50s and seemed very confident this doctor did not come to speak to the family that day but it was revealed to them later that he found that Martha was much worse off than they’d been expecting neither Prof Richard Thompson nor the surgeon were

Seen Again by Martha’s family that day in fact fact it turns out that profer Thompson had entirely left the hospital early taking a half day very early in the afternoon leaving Martha in the hands of two Junior doctors one of the two was more experienced and maripi

Described him as Dr blunder within her article stating that he and Prof Richard Thompson had Direct impacts on Martha’s passing in this case there was a common theme of Martha’s care being left in the hands of Junior doctors in theuk okay a junior doctor is essentially a medical

Student who’s working as an intern as part of their medical training marpie revealed that at the time in 2021 that she had no idea that the Consultants were still being trained or still students believing that they were more practiced than they actually were she described how despite seeming so young

They Carried themselves with so much confidence it seemed that they knew everything regarding Martha’s care in fact she outright stated in her article that there were many times where she had no real idea as to who was even in charge of her daughter’s overall care due to the amount of times they

Alternated between different Consulting doctors many being Junior doctors should be noted this isn’t meant to dismiss the professional experience of Junior doctors they have successfully completed a medical related Bachelors however they’re still learning and training and are not at the level of a fully fledged attending physician each day the family

Often saw different Consultants who they always make sure to ask necessary questions regarding the status of Martha’s treatment despite the confusion on who exactly was in charge of her care they always ensured to show the Consultants their gratitude hoping to bring out the best in their care after

All they were the experts and the treatment of their daughter was in their hands but unfortunately it was the same care team who played a role in Martha’s tragic passing on that Sunday during the bank weekend by lunchtime Martha had a high fever very low blood pressure a racing

Heart and did in fact have sepsis a serious incident report or sir that would be written up by a man named Prof William Bernell after Martha’s passing noted that it was at that point that she should have been moved to the for immediate intervention this was confirmed directly by the writer of the

Report to marapi as well however over a call Prof Richard Thompson dismissed the idea immediately later noted during the investigation of the incident that he and other high status Consultants working in the Raz of sunshine Ward were dismissive of those working in the piku seeing them as lesser or inferior

Doctors Marie described in the article that quote this made them reluctant to do the right thing and involve intensive care saying that Martha died in part because of inflated egos as the afternoon continued Martha had developed what was described as an angry red rash that spread across her

Neck her torso and her legs this too is another major sign of sepsis and although Dr blunder hadn’t worked with the case like Martha before he was still overly confident and dismissive even when told by marpie that she feared the rash was sepsis related he was convinced

And stuck to his belief that the rash was caused by a delayed drug reaction so a concerned marpe left Martha’s cubicle and after finding a nurse she expressed all of her worries about Martha’s condition she explained how she was concerned that Dr blender’s diagnosis of the ratch was false and how when looking

At the symptoms online it seemed evidently clear that Martha’s rash was sepsis related however this nurse put her hand on Marie’s arm and just told her don’t look things up on the internet you’ll only worry yourself trust the doctors they know what they’re doing later in the day around 5:00 p.m.

Martha’s bedside Pew score had been upped from the initial six they had her at to and eight and at that time Dr blunder had called Prof Richard Thompson to let him know about this change however he didn’t alert marpie or Paul about this not only this but even

After his second phone call a while later Prof Rich Thompson had still decided to not come in and see Martha and she still wasn’t moved to the piku which is odd because as part of his position Prof Richard Thompson made routine calls to the piku however in

This case he decided to not disclose all of the details regarding Martha’s overall situation to them and ended up only explaining part of her chart during these calls he failed to include information regarding her bleeding or her new rash he explicitly stated in these calls that she had called them for

Information only and stated that no review was needed essentially saying that Martha didn’t need to be checked in on or by any staff working in the piku in the hospital there was a policy implemented to listen to parents parents and escalate accordingly if concerns of their child’s health continued however

Despite this policy he chose not to move forward with the situation by bringing Martha to the piku which again is wild because he was informed that a bed was available in the piku for Martha if needed yet he was convinced that he was 100% sure it was not needed mayor

Disclosed that neither She nor Paul knew enough about what was going on to feel safe or comfortable challenging the doctors or making any demands which is very valid and fair no parent should be expected to have extensive medical knowledge to save their child well quite literally standing in a hospital with

Professionals whose job is to be the medical provider and no one to make reasonable decisions in the care of their patients when evening rolled around that day the family was assigned a new Junior doctor for the night whom marapi referred to as Doctor do nothing and although a nurse had passed Martha’s

Worrying charts over to doct do nothing she didn’t ever come down to Martha’s room to check in on her sometime that night Martha was feeling extremely thirsty and she began drinking and inordinate amount of water which mayp described as an unquenchable thirst this serious thirst yet again is another sign

Of severe sepsis and all Marie could do was continue comforting Martha she told Martha that she would get through this but by that point Martha had been through so much she responded by telling her she heard that that so many times that it had lost all meaning and the

Nurse was notified of this multiple times but yet do do nothing still did not come in to check on Martha despite only being a couple meters walk away and Martha’s condition continued to get worse just to note the following description is sonographic however these are details shared by her mother

Directly depicting what Martha went through early in the morning at 5:45 a.m. Martha attempted to stand up to use the toilet however when she tried to sit down it was painfully clear that she would not that that would not be possible Marie horrifyingly watched Martha as her body went stiff and her

Eyes rolled back before catching her as she collapsed Martha began to seize and was convulsing in her mother’s arm by that point Marie panicked and began screaming out for help and as she held Martha In Her Arms Martha was having intense diarrhea just before the nurses

Arrived in her room to help it was said that her seizure was caused by a lack of oxygen to her brain due to the deterioration of her internal organs again another sepsis related issue by the time a nurse got to them Martha had come out of the seizures and allowed the

Nurse to start looking after her so that her mother could clean herself up at that point marpie had pulled the senior nurse aside and before she could even ask the nurse said to her look Martha’s not going to die pull yourself together and so Marie washed her face in the

Bathroom and then she returned to Martha’s cubicle trying her abs absolute best to hold it together Martha at that point had mostly lost all hope Marie shared that Martha and I were alone together when she hovered her hand above her torso and looked at me with fear in

Her eyes and quietly said it feels like it’s unfixable at night these words wake me in a surge of Terror and panic after Martha’s seizure the care team decided to do a blood test and it was from this particular blood test that Dr do nothing finally realized

That Martha was indeed lethally ill so after days of being septic and uncounted hours of being in septic shock Martha was finally taken to intensive care however by that point it was so late there was nothing that could be done to interrupt The Vicious cyc septic shock

Despite the picky you crew trying their best to find a solution there was unfortunately very little they could do for Martha at that moment they tried putting her on supplemental oxygen but her breathing was unfortunately not strong enough to PR Prov the correct amount of oxygen to her brain by that

Point Martha was very out of it she was confused and in one instance she believed her oxygen mask was meant to be putting her under anesthesia moments after this a tube was forced down Martha’s throat though its purpose was not explicitly described it could be assumed that it might have been an intubation

Tube she was then administered a strong sedative marpie told her she loved her and Martha subsequently fell into a coma that she would unfortunately not wake up from Martha passed away on Tuesday the 31st of August 2021 a mere 4 days before her 14th birthday on the 4th of

September before her passing there were last minute talks about moving Martha to another hospital called the Great Orman Street Children’s Hospital this idea was in El lastage attempt to attach her to a machine that would act as a heart or lungs outside of the body but this did

Not happen a huge problem in this case was the medical team’s lack of communication of what was going on with Martha’s Health Martha bleeding through her clothes and bed sheets was a sign of severe sepsis yeah at the time doctors described it as a normal side effect to

An infection and did not explain it could indicate severe sepsis to the family this was also a rarely seen issue with the procedure Martha had and her injury which was also unknown to her family at the time the doctors at King’s College just constantly assured the family that this

Was an infection and avoid and avoided the use of the word sepsis marpie described while the doctors knew she had sepsis they never used that word when talking to Paul or me just infection I wish they had because I would then have found out more the family wasn’t even

Informed that on Wednesday the doctors had ranked Martha as six on the bedside Pew scale until after the fact which would have been crucial because the score being this high should have at the very least prompted discussion of Martha being moved to intensive care not only

This but they had conducted a scan on Martha showing that she had a small amount of fluid surrounding her heart this too is another sign of sepsis yet again the family was not told about this and action towards this was delayed until after the bank weekend and even when blatantly expressing their concerns

For Martha’s symptoms being sepsis related they were shut down and to believe that there was no way she could be going through sepsis at the time they described meropi in the medical notes as very distressed yet they constantly tried to convince her that everything was all under control maripe quoted her

Injury was treatable she became the first child on record at Kings to die of it after the care for her became careless her preventable death is an example of what a hospital official described to us in a barbarus phase as a poor outcome Martha’s condition was treatable severe sepsis is able to be

Treated when a patient is taken to an intensive care unit on time so that they could be administered powerful drugs and have frequent interventions to treat it which is especially horrible because it was later shown by the hospital incident report that there were five instances where Martha’s case should have been

Transferred to the piu but simply was not her care team knew she had sepsis 6 days before before she passed away yet nothing was done about it something notable that stuck out during their stay was that one day as Martha’s family sat in her room and helped care for her by

Doing things such as washing her hair and other small tasks a scene unfolded that could easily have been seen as a omen Marie described that while she was downstairs on the ground floor of the hospital replenishing the snack Supply in Martha’s room she recounted that two women were very angry and one shouted

Effing murderers while the other yelled let’s get away from the effing Killers while this was odd at the time marpie said she recoiled and instinctively took the side of the doctors Looking Back Now I’m sure you can imagine some reasons why these women could have been shouting

That out in the hospital on the 3rd of September 2021 coroner me Hassel who was a senior coroner of St panr Corner’s Court in London began an investigation into Martha’s passing the inquest was completed on February 25th 2022 and it was sent to the relevant parties within

The case before being made available to the public within the published prevention of future deaths report it was blatantly stated that had Martha been moved to the proper intensive care the likelihood of her surviving her injuries was incredibly High included in this report were also Martha’s official death circumstances and it listed the

Factors that contributed in her death as refractory shock sepsis pancreatic transex operated and abdominal trauma the report also noted that the bedside Pew system for Pediatric cases at Kings College was still paper based as opposed to being electronic like the adult system they had this was another Factor contributing

To the complications of Martha’s case as staff at King’s College outright stated that the system as it was was suboptimal had the bedside Pew system for Pediatric cases been electronic at the time this could have automatically alerted the piu of Martha’s condition prompting the chancer out the W she was

In into the appropriate intensive care furthermore the report states that the ball was dropped between the Pediatric hepatologist and the Pediatric intensivists in other words the team that was responsible for working on cases regarding the hepatic system which would be cases regarding the liver the pancreas and other related systems did

Not coordinate with the piku staff well enough to have provided Martha with adequate care the report also notes that there was a transition happening in regards to the bedside Pew system within King’s College but that it was stalled due to the pandemic at the time thus the coroner’s recommendation included the

Continuation of the transition to digital bedside Pew charts for Pediatric cases and forther to be work to better integrate the different staff teams at the hospital in order to ensure cohesive work because it was clear there seemed to be a lack of proper transparent communication going on between the

Different teams during Martha’s case within the hospital’s investigation it was found that the doctors who’d been overseeing Martha in those last few days seemed to lack empathy for Martha her family and the situation they’re in and because of all that had gone on the hospital later issued a public apology

To them but the thing is the sentiment was more about Lessons Learned and Promises to do better more so than the emission of failure on their part something else that’s very notable is that within one week of the mishandling of Martha’s treatment and her passing away Dr blunder was actually promoted

From Junior doctor to consultant just based off of this at that point it seemed as if the hospital with her apology was more so focused on PR and damage control as opposed to actually fixing the core issues that led to Martha’s passing due to Marie’s job at the guardian public Outreach regarding

Martha’s malpractice case was quite notable between the large platform of the Guardians Med and the gripping story from her mother’s point of view Martha’s story was naturally covered rather quickly after the first article sprang up as the hospital began to respond publicly about the incident more and

More media Outlets began to cover the story many of which noted the lack of Care on the part of King’s College because of the blatantly obvious mistakes the hospital staff made as well as the obvious need for a fix it was just within a year of Martha’s family releasing articles for politicians to

Pick up the story with interest and push for change this is when they opened up the idea of Martha’s rule a rule created to fix the escalation systems in hospitals by providing patients the right to rapidly access a second clinical opinion in Urgent or contested cases on February

21st 2024 the House of Commons debated the implementation of Martha’s rule within NHS hospitals in England within her address Victoria Atkins the Secretary of State for Health and Social care informed the house of what had happened to whilst under the care of the staff at King’s College Plus members of the House

Had been made aware of the initiative behind Martha’s rule around mid-september and several members and politicians were speaking out in favor of it on September 13 2023 former prime minister Teresa may backed the campaign for the implementation of Martha’s rule publicly stating that more needs to be

Done in terms of death prevention in another article and in Martha’s demos report it’s noted that a similar bill had been introduced in Queensland Australia and had been successful in preventing several patient deaths this one is called Ryan’s role and it was implemented in 2007 after a boy named

Ryan Saunders passed away from toxic shock syndrome after suffering from an undiagnosed strep infection despite his parents expressed concerns mayor P Mills welcomed the announcement saying I met the Secretary of State for health yesterday and welcomed the news that he will introduce Martha’s rule across NHS England Hospital hital he is

Prioritizing its introduction and is ready to allocate funds to the initiative it will be one standardized and recognizable right that will become part of patients experience on Hospital Wards in terms of changes within the NHS Martha’s rule has three primary focuses that all staff within NHS Hospital trust

Are required to have 247 access to a critical Outreach team who can perform rapid reviews of a patient’s conditions when concerned that all patients families Advocates and carers must have access to the same review team which can be contacted by various mechanisms advertised around the hospital and that

A structured system is to be put in place to share information about a patient’s condition directly to patients and families at least once a day just to clarify a trust is a public sector body established by parliamentary order by the Secretary of State for health to provide Healthcare Services to the NHS

Primarily the main focus of Martha’s rule is to ensure that patients families carers are able to obtain accurate information about their condition and have more agency to make choices in regards to their treatment it gives patients and their families the legal right to a second opinion ensuring that

Quote patients families and carers would have the power to directly contact an independent Critical Care team and ask them to conduct a review of the patient’s condition if their condition is deteriorating or they have other serious concerns with this the 24/7 rapid response team will be built within each hospital and

Therefore be made up of slightly different types of Physicians based on what staff are available at each trust and patients will have access to medical professionals that aren’t part of their care team to discuss any concerns they may have some people did have concerns about this rule they worried that with

Martha’s rule in place hospitals might have resourcing difficulties which would affect all these scarce NHS resources however the UK has a patient safety the initiative called call for concern or c for C it’s believed to be the first scheme of its kind in the UK where patients and relatives can directly call

Critical Care teams if they’re concerned about a patient’s condition this scheme was first introduced in September 2009 and was implemented in some trusts across the UK in the demos report for Martha it stated that in 2019 a further evaluation of c4c referrals in Royal birkshire was carried out over a 7-year

Period 500 34 calls to c4c were made the study found the service was being appropriately activated with only 5% of referrals deemed not to be a c4c thus just based on this it’s very likely Martha’s rule will be used sensibly in that nhsu resources won’t be affected as

Much as one may be concerned regardless though this shouldn’t be a concern for worried patients and families in the hospital all they need to be concerned with is being able to have access to this service despite the issue of varying staff per hosit Hospital the NHS

Stated that the aim is to have a standardized approach in implementing Martha’s rule ensuring that most hospitals have similar teams and responses in regards to it during the Parliamentary discussions of the rule on February 21st 20123 it was decided that the roll out of this rule would happen

Gradually throughout NHS NHS trusts in England so that adaptations to the way hospitals adopted it could be adjusted as needed and this will be happening fairly soon select hospitals will begin adopting Martha’s rules starting in April 2024 where 100 hospitals should have the rule adopted by these first 100

Hospitals will have this 24/7 escalation service initially funded by 10 million pounds of government funding accounting for around 2third of those in England it’s said that hospitals in England are welcome to apply or to join the program themselves however all hospitals in England will eventually be phased in unlocking further funding after

Evaluation of the program the current timeline anticipates all hospitals will have implemented Martha’s rule by March 2025 with the exception of specialized hospitals specialized hospitals are such as Community Hospitals mental health hospitals or instead aiming to integrate Martha’s rule by 2026 all in all it should not have taken a young girl like

Martha to lose her life in such a painful and avoidable death for patient doctor transparency to have been addressed by the NHS and government in England however Martha’s rule as most rules are is born from the blood of those the rule would have protected if featured sooner within the UK a notable

Number of citizens who utilize the NHS system felt that communication with their carers was not adequate a study from 2019 surveyed 2,471 patients who had care provided to them from three separate NHS trusts in England it was found that 23% of these patient ptients had concerns about their

Care and communication was found to be the most cited issue listening to patients and communicating with them effectively is one of the most critical aspects of properly practicing medicine a patient knows what they’re feeling because they’re the ones going through it regardless if you agree with the

Patient’s opinions or not you should be making sure that you do what you can to ensure that they are heard and that they are provided the service they feel is best for their body especially when you know they’re going through something like sepsis and that there are steps to

Take to not only help them feel better but to effectively treat it had Martha been protected under a rule such as the one born from her tragedy she would have been 16 years old and well into her secondary school years now hopefully the roll out of Martha’s rle will provide an

Extra layer of safety and comfort for patients of the NHS and their families within England and that it allows for voices to be heard but yes that is it for today’s video what are your thoughts on this case please comment your thoughts below and don’t forget to

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