Senior doctor admits 'doubting his own judgement' after a teenage girl died from sepsis - but tells tribunal he did not make any wrong decisions
A senior doctor said he 'doubted my own judgment' after a teenage girl died from sepsis - but told a medical tribunal he did not believe he made any wrong decisions.
Professor Richard Thompson is accused of numerous failings in his treatment of Martha Mills, 13, at London 's King's College Hospital two days before she died in August 2021.
More than a month earlier Martha had suffered an injury to her pancreas after she fell off a bike while on holiday in Wales.
She was later transferred to King's College Hospital, one of three locations in the UK that specialise in the treatment of children with pancreatic injuries.
The consultant hepatologist saw Martha on a morning ward round on Sunday, August 29, after she experienced fevers and an increased heart rate in the days prior.
She was given intravenous fluids that day as her blood pressure was low, a Medical Practitioners Tribunal Service (MPTS) panel heard.
Professor Thompson said: 'She was very much awake and interacting, she was having the fluid. She was clearly not well but she was warm, well perfused, talking and making complete sense.'
The fluids were increased from late afternoon when the blood pressure reading was still low.
The duty registrar called Professor Thompson at home when Martha developed a rash.
Professor Thompson said: 'He gave a description of a rash in many places... it was very suggestive of an allergic rash and not a septic rash. I had no reason to disbelieve his description.'
He said the registrar was 'at the most experienced end of a junior doctor that you could have' as he was completing his final months of training.
Professor Thompson said he could not recall the figures from blood pressure and blood test readings that were relayed to him before he phoned a consultant colleague to consider whether Martha should be moved to intensive care.
The General Medical Council (GMC) says Professor Thompson gave 'outdated' information about those readings which gave the false impression that Martha was stable, and that he also failed to mention her rash.
The GMC also says he should have returned to the hospital to review Martha himself after he was informed about the rash and should have acted sooner in recommending a critical care review.
Martha collapsed the next morning and was moved to intensive care before she was transferred to Great Ormond Street Hospital, where she died in the early hours of August 31.
After her death, Professor Thompson decided he would no longer provide inpatient care as he became 'extremely cautious', the tribunal heard.
He said: 'I was doubting my own judgment. I don't believe I made any wrong decisions but I thought it better to remove myself from that environment and contribute to other work in the department.'
His barrister Ben Rich asked: 'Did you ever doubt your judgment in Martha's case?'
He replied: 'Absolutely. I think I was on record saying that I felt I made a mistake and other times I said I didn't.'
Professor Thompson denies all the allegations against him.
The hearing in Manchester continues.
At a 2022 inquest into her death, a coroner ruled Martha would most likely have survived if doctors had identified the warning signs and transferred her to intensive care earlier.
Martha's mother, Merope Mills, an editor at The Guardian, said she and her husband, Paul Laity, raised concerns about Martha's deteriorating health a number of times but these were not acted on.
The couple later successfully campaigned for Martha's Rule to give patients, families and carers the chance to easily request a second opinion from a senior doctor in the same hospital in the event of a suspected deterioration or serious concern.
Earlier this year the House of Commons Health and Social Care Committee was told that more than 100 patients had been taken to intensive care 'or equivalent' as a result of Martha's Rule, and that patients, their loved ones or staff had raised concerns about care using the rule on more than 2,000 occasions.
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They could see their daughter was struggling."She sat there almost in silence, tears were rolling down her face," remembers on the night of 6 July, Alice and her boyfriend exchanged messages with each other, talking about their love of Bob Dylan's music. At 23:30 he wrote: "I can't stop thinking about you, x."The court heard that around that time Alice had asked to speak to a care assistant she got on care assistant was called away to an emergency elsewhere in the hospital. When she returned to Hepworth Ward she looked for Alice. She eventually found her slumped in the communal by two nurses on duty on Hepworth Ward slowed the arrival of an on-call doctor and paramedics. Alice was eventually taken to another hospital where she died."It's a moment where your entire life has changed and will never be the same. That's what we have had to learn to live with," says Jane. 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When they weren't able to get documents through official routes, they'd find other ways to get them, working like seasoned they had them, they'd analyse them and produce detailed reports that they sent to the police and regulators."If I could discover something that would be helpful to their investigation. I would try to do that. We were a parallel investigation," says Jane. All this digging came at a financial cost."We were in our 50s, we both stopped working and actually sold our house and lived off that to be able to do this," says emotional price was even higher. "You can't underestimate or even find the words to say, the toll that that takes on you. It's profoundly re-traumatising," she were further shocks to come in Alice's medical notes, which showed gaps in the hospital's official SI report. They had been told Alice had attempted to self-harm with plastic bags on 13 occasions, in fact it happened at least 18 of these incidents weren't recorded in logs as they should have been."It still shocks us to the core today," says the unit, plastic bags were not used in the bins in patient bedrooms for safety reasons, but they were in a few communal locations, including a toilet that was often left unlocked. Alice used these bags to self-harm on multiple occasions, including the incident that led to her trial heard there was little evidence that ward manager Benjamin Aninakwa made any attempt to restrict access to those bin bags, despite the issue being raised with him, and it appearing in Alice's care did not appear as a witness in court but told police the toilet door was locked and he had been overruled when he tried to remove the bin bags. The court heard there were no emails or evidence in Alice's clinical notes and records to corroborate this.A Care Quality Commission inspection in April 2016, the year after Alice's death, found bin bags still being used on the unit. The bags were eventually court heard that around the time Alice was admitted to the hospital for the final time, the Trust was carrying out a "scoping exercise", which looked at removing all plastic bin bags from the hospital's wards. It was revealed a bin which didn't need a plastic liner had been considered – it would have cost just £1.26."NELFT placed more value on their rubbish bins than they did on my daughter's life," says a statement, the Trust said: "Our thoughts are with Alice's family and loved ones, who lost her at such a young age. We extend our deepest sympathy for the pain and heartbreak they have suffered this past 10 years."We will reflect on the verdict and its implications, both for the trust and mental health provision more broadly as we continue to work to develop services for the communities we serve."Jane and Max Figueiredo say they wanted to hold those at the Trust to account, but that they also wanted change for the future. But there will be no celebration at Monday's verdicts."Nothing will ever bring Alice back to us and we will never stop thinking of her and missing her," says Jane. "There's always one place empty at our table, one very special voice silent that we long to hear in our conversations." If you are suffering distress or despair, details of help and support in the UK are available at BBC Action Line.
