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 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.
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.
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.”