‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death

36 comments
  1. An absolutely harrowing read, you can see the disaster coming from a mile away but just feel angry for the parents as not nearly enough is done to stop it.

  2. A tragic and perhaps avoidable accident, because the Mum is a Grauniad Editor it’s news but in the context of 67 million people using the NHS there will always be mistakes and any child dying is irredeemably sad.

  3. As always the hospital like to cover their own tracks and put it down to some learning experience for better procedure in the future. The doctors should have been disqualified, I know they can’t save everyone but the fact the mum saw the potential dangers a mile away, they shouldn’t just simply get a slap on the wrist. That’s disgusting one was promoted, and for what they did bugger all

  4. Awful and all too familiar. I’ll preface this by saying our family owes our child’s life to the NHS and there isn’t a moment I wished I was elsewhere BUT its a long way from perfect.

    For example, we are under strict instructions to avoid our local hospital at all costs but to drive them to a further A and E if at all possible.

    But even when we once did have to do so, due to a major infection following discharge from a major surgery on a critical organ, it took a senior doctor from the specialist hospital demanding it before the local hospital would release us back into the specialist care. The Doctor literally looked at me and said “I know what I’m doing, we are perfectly capable here” rather than approve our request to move him back to the hospital which he’d left days prior.

    I also once made the foolish mistake of googling our consultant, to find he’d been called to give evidence in a case where a colleague made a catalogue of mistakes leading to our consultant attempting to save the life of a young child in our same hospital.

    We’ve been forced, at times, to advocate HARD for our child’s proper care – especially at local hospitals. And it’s awful, you know they’re trying to do a job but sometimes you also know they simply aren’t doing good enough

  5. It’s appalling and disturbing that Martha’s obvious decline into sepsis was dismissed by so many medical professionals. What spirit she had. The poor wrenched family.

  6. Even though you know what happens in the end you hope it ends up with her doctors recognizing the signs of Sepsis and her being sent off to the PICU but it doesn’t 🙁

  7. I’ve had sepsis from my pancreas. In my case, my pancreas had become necrotic and spread infection to the rest of me. I had emergency surgery and it was whipped out, which undoubtedly saved my life. I was about 15 when this happened. It was touch and go. I was pumped full of antibiotics, put on intensive care and given all kinds of drugs. My mum was told to prepare for the worst.

    The doctor who failed to notice that Martha was so unwell needs to be struck off. Pancreatitis can be fatal, it isn’t a minor injury. If sepsis is involved, it needs to be treated aggressively. Failing to do that is negligence. There are no other words for it.

    Martha should have survived. If my illness, 7 years earlier was treatable then Martha’s was. It was an arrogance and a failure to act that killed her. An assumption that because they were working in a world leading hospital, they could do no wrong. Humility is a crucial trait. Arrogance is fatal.

  8. Slightly off-topic but reading this made me think of a cardiac issue I’ve been going through over the past year. At times it’s been so bad I’ve been paranoid I will go to sleep and just not wake up.

    Dealing with the NHS has been insane. I’ve fully documented who I’ve spoken to, what I’ve been told, where I’ve been sent, what tests were run, etc. It’s now running into thousands of words.

    I’ve had test results go missing multiple times. Been sent an hour away to walk-in centres that don’t actually exist, to be turned away again. Had multiple referrals cancelled with no explanation. Worn monitors on multiple occasions that weren’t turned on properly, sometimes for a week. This is off the top of my head.

    * I sent a complaint to my GP practice that was totally ignored.
    * I complained to the NHS and they said they couldn’t do anything as I’d already complained to my GP (even though I told them I’d had no response). They offered to chase my GP to reply, but that made no difference.
    * I complained to Healthwatch, who referred me to the Care Quality Commission. They acknowledged the complaint but said they couldn’t give a response.
    * I complained to PALS, who essentially shrugged and said nothing they could do.
    * I looked into complaining to the PHSO and the reviews were so bad and defeatist on Google that I thought I’d just be wasting my time.

    After having multiple referrals over months cancelled for no reason (this was actually at Kings College hospital too) I paid hundreds to see someone privately. They told me the next steps for tests were so expensive, that I may as well be referred back to the NHS to have them done for free.

    “Great” I thought, nearly on track now. That was back in April and I’m still waiting and struggling. I just feel like it’s totally impossible to get anyone to listen or take it seriously. Everyone individually has been really nice but the system as a whole seems insurmountable. At this point I have no idea who to speak to/what to do.

    This article reminded me that at one point recently I dreamed that I’d died and was basically in an article like this – “Multiple chances missed to save person’s life” – while everyone shrugs. Sorry for the rant.

  9. ALWAYS google. Your child’s teachers, caregivers, doctors, nurses, neighbors, meds, symptoms etc. Always try to get a timeline- you say this is X, you are treating her for X, how soon can we expect improvement, what if she doesn’t improve, what else can it be, what’s next. Ask for tests results, options for care, WHY is she not improving, second opinions, ask the doctor about his/her experience in treating X. There is no trust.

  10. Beyond appalling. Calling PICU Consultant or Outreach for a review and opinion costs nothing. Where was the most basic humility – “could there be something I’m not seeing?”

  11. Some head honcho decided to act against hospital policy out of sheer arrogance:

    >When Prof Checked Shirt made his routine call from home that evening to the head of PICU, he painted only a partial picture of Martha’s condition. […] He was relaying her details “for information only”; intensive care “categorically” should not pay Martha a bedside visit, he said: “no review was needed” and it would increase my anxiety. The hospital’s policy dictates that parents being worried is a reason to escalate; he decided the opposite.

  12. This was so heartbreaking to read.

    The hierarchy that exists in hospitals is one of the reasons a relative of mine quit her job as a doctor – some consultants are arrogant and won’t listen if they feel their opinion is being challenged and they’re threatened by doctors more junior than they are. My brother is a nurse and has said before that doctors are sometimes scared to challenge a consultant.

    I cannot imagine the grief that this poor lady has to live with, as well as the “what if”.

    My father-in-law died of sepsis and it wasn’t diagnosed until after he’d died whilst having an MRI scan. NHS literature is very clear about sepsis symptoms and the need to be vigilant but the hospital staff weren’t ‘on it’ with the sepsis diagnosis (or didn’t inform us if they were).

  13. Horribly tragic series of events. No parent should outlive their child.

    May lessons be learned and for this to not happen again.

  14. I know the mother and I’ve heard her tell her daughter’s story in person. We share the same grief of child loss. Guilt seems to be something all bereaved parents carry. We all feel we should’ve protected our children somehow. Should’ve known something was wrong/was going to go wrong, should’ve made different choices, shouldn’t have trusted that doctor etc It’s maddening.

  15. devastating read – as someone who had their daughters in NICU at birth, I can absolutely see how things can go wrong, and have seen the circle close instantaneously when I challenged some nurse behaviours that were dangerous. I cried when I read this – feel such sorrow for the mother, father and sister…

  16. Such a terrible, terrible set of circumstances. As the father of a 14 year old, I found this difficult. I can also reason with the final message, after getting the vaccine last year I was left with DVT. The clinician I saw, I felt, was kind of pissed off that I’d suggest what I thought it was potentially causing my leg to swell.

    Even 2 weeks later, when I arrived back in her room, with the same swelling returning once the course of naproxen finished, she still denied it was blood clots. Only at the very last minute before I stood up did she decide to take some blood.

    She was an angry, shitty clinician. I refused to see her after that, her attitude sucked and I was lucky not to die.

  17. This is heartbreaking. Those poor parents will play this over and over again in their heads for the rest of their lives thinking about all the times they should have said something or insisted on a second opinion. It’s not their fault, the medical staff forced them to trust what they were doing. So sad that there were many opportunities to save her but arrogance and incompetence led to her death.

  18. Not NHS but my grandma died of sepsis this year because care staff were failing to give her the correct medication/care and it felt horribly unfair she went out like that, I can’t even imagine what this poor family have been through.

    You can really feel her love for her daughter through the page.

  19. My daughter had an infantile haemangioma on her neck and jaw area. They are a benign tumor made of an overgrowth of blood vessels. Usually they aren’t serious and easily treated with propranolol and will disappear by the time the child is two.

    My daughter’s was growing daily, to the point where her face was becoming distorted and the normal skin around it was turning blue with the amount of blood beneath the surface. I took her to the GP weekly because I was so scared. The GP kept saying it wasn’t her area of expertise and to wait for the referral to the hospital.

    Eventually she was seen by a paediatrician who looked at ir and gave propranolol. It carried on growing and the propranolol wasn’t doing anything. When we went for a check up 4 weeks later it had started oozing a smelly brownish liquid. The paediatrician didn’t examine it, he just upped the dose of propranolol. She was 3 months old at this point.

    That night the haemangioma burst open underneath. She was on her changing mat in a pool of blood, i had blood up to my elbows. We called an ambulance, waited 40 minutes while I was trying to apply pressure to her neck without essentially strangling her and we were taken to hospital.

    After 4 days we were transferred to a tertiary hospital and saw the regional consultant. He did a biopsy and an MRI. Turns out it was fed by the main artery from her heart to her brain and if I hadn’t have applied that pressure to the bleeding she would have bled out and died. The bleed made her anaemic, but luckily she didnt need a blood transfusion The surgeon cried when I asked if she might die and she said, yes there is a risk she might bleed out if it bleeds again. There was no option of surgery because they wouldn’t be able to stop the bleeding. Absolutely horrifying and terrifying to hear.

    It had ulcerated underneath and that’s what the smelly liquid was. The original doctor didn’t even examine it. It took the highest safe dose of propranolol, 6 rounds of steroids and countless weekly dressing changes and she’s left with some scarring and a little bit of excess skin as it has FINALLY involuted and almost disappeared. She’s almost 5 now and about to start school.

    I still will always believe in the NHS and know what an amazing job the staff do. The consultant we saw at the tertiary hospital was amazing and I couldn’t ever thank him enough for everything he did for my daughter. But we were SO close to losing her, all because we were just given more meds and essentially sent away again.

    Edit spelling and formatting.

  20. You should always question the judgement of every profession you deal with if you are involved in serious situations, hospital, law, accountancy.. endless list.

    a simple google (like in this case, but in many cases across many professions) reveals often they really have huge knowledge gaps or simply lack an acceptable level of competence

    It is very widespread – we are not talking about mistakes here – but plain negligence – far more common than many folk think

    In this case parents should refer the clinicians to the GMC – and then make sure the hearings and outcome are heavily scrutinised

    GMC thankfully in many cases doesn’t give out the “lessons will be learned” trump card in my experience

  21. I love the NHS, but this can only be described as a catalogue of avoidable errors caused mostly by the arrogance of the doctors providing care. The consultant deserves to be investigated for his ego and arrogance.

    As a former student at Aber University, I can tell you that Bronglais hospital was well known and feared. People used to joke that you wouldn’t come out alive if you went in. Food for thought.

  22. unfortunately this is not a one off case. people are treated like this by hospital staff all the time which is why i will *never* laud the nhs.

  23. Yet again showing the dreadful state of the NHS, but people continue to defend and glorify it. Radical change needs to happen, whether that be privatisation or something else.

  24. This is incredibly sad, but as a clinician I don’t think you can claim that a single blood test would have saved her life. It does sound like she needed PICU earlier but even then she may have still died.

  25. As someone whose life was saved twice by the NHS I am not afraid to say there were doctors I did not have any trust in, and others that I did. In fact there was a point when my other doctors from another department who were responsible for my ongoing care for my previous treatment had to step in and take me away from the care of another department because they were, essentially, incompetent although the other doctors never outwardly described them as such. And this was at one of the largest hospitals in the UK.

    Soon after my first major time spent in hospital income to realise that doctors, just like anyone else are just people doing their job. Some people are bad at their jobs, some people are okay, some are great, and the same goes for doctors.

    I had doctors often express to me surprise that I could understand to a fairly good degree what they were talking about and didn’t have to “dumb things down” too much. I don’t know if that’s because I had been sick for so long but I came to realise that I was more of an expert on my body and what was normal, what was wrong and what I needed to tell them than they ever were going to be. It was at this point I realised I would need to question everything, ask for explanation on what or why they were doing certain things, what they’re plans were etc. You really do have to take such a proactive part in your care, which when you are sick is not always an easy thing to do.

    I also echo her statement that care on weekends in hospital is borderline shocking. I can’t say I ever felt that scared for my life in hospital, even when going into major surgery, as I did at the weekends when I was in recovery on a normal ward (obviously intensive care and high dependency are better).

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