‘If any good comes from my daughter’s death, it’s that parents’ fears will never be ignored by doctors again’: The story of how 13-year-old Martha died needlessly is shattering. Now, her mother tells how hospital failures sparked her campaign for change…

I used to say how lucky I was to have such a wonderful family life — as if acknowledging my luck would keep bad things away. It didn’t work.

Two years ago my daughter Martha died needlessly in hospital a few days before her 14th birthday.

She was a teen with an easy laugh and many enthusiasms — for music, food, books.

She could do many things better than my husband or me and I was in awe of her determination and the originality of her mind. 

That her death was avoidable somehow makes her absence all the more painful.

Because I miss and love her so, I am calling for ‘Martha’s Rule’ to be introduced across NHS hospitals in the hope that no other family has to go through such horror.

In the summer of 2021, we were on holiday in Wales and hired bikes to cycle a safe family trail to the beach. 

On the way back, Martha slipped on some sand and fell off her bike in such a way that the end of the handlebars hit her abdomen very hard (she had an ‘O’-shaped bruise).

After going to the local medical centre and then A&E, we found out that Martha’s pancreas was ruptured, and she was helicoptered to King’s College Hospital, in South London, which is one of three national centres of expertise for treating the trauma. 

It’s a tricky but not unheard of injury; no child at King’s has ever died of it.

Until Martha.

We ended up on Rays of Sunshine ward, which is run by the high-status paediatric ‘liver team’, described as ‘world class’.

My husband Paul and I spent alternate days at Martha’s bedside and we kept being told we were in the best place; Martha was assured she’d be back at school before too long.

We watched TV with her and arranged visits from friends; she put up pictures of our cat on the cubicle walls.

We know the details of how things went catastrophically wrong because we’ve asked King’s endless questions and investigations have been conducted into Martha’s death.

A few weeks into her time on the ward, she got an infection. After a couple of days she deteriorated and started to bleed through her tubes so that blood was soaking her sheets. 

This was a very serious development. She had fast breathing, a fast heart rate and a fever.

At this point the nurses stated that Martha was ‘at risk’ and should be moved to intensive care. But there was a particular culture on Rays of Sunshine ward. 

The hierarchy in place meant that the senior doctors didn’t seek to find out the nurses’ opinion. 

These consultants had never seen bleeding with Martha’s injury before, and didn’t know the source of her infection.

But it seems that because they were used to treating chronically ill children they thought they had all the answers.

It turns out that the doctors knew at this point that Martha had severe sepsis, but neither Paul nor I were told this. 

Her bleeding was, we were reassured, just a ‘normal side-effect of infection’.

In retrospect, this was dangerously misleading. We weren’t told of other serious symptoms, and were kept in the dark and ‘managed’.

Even if it were argued that the consultants withheld information to stop us worrying, the result is that they took away any agency we had to demand the appropriate care for our child.

Investigators have said that Martha should have gone to ICU at this stage, but she stayed on Rays of Sunshine ward. 

One reason, according to the external investigators, was that many of the very experienced liver team consultants had ‘complete disregard’ for junior colleagues in ICU.

They kept Martha on their ward: we have learned that they would have regarded moving her as a ‘sign of weakness’. Pride and overconfidence can lead to fatal errors.

A national expert on sepsis worked in paediatric ICU but his opinion was never sought. 

The liver team doctors, we were later told, never attended the optional sepsis training at King’s. No one was in overall charge of Martha’s care. 

Different consultants came and went every day, which meant no one was alert to her trajectory — to the fact that she was deteriorating in front of their eyes.

What’s more, the consultants didn’t even write down notes about Martha’s care, so there was no continuity of thinking.

‘The documentation is dreadful,’ King’s has admitted to us.

On Friday, Martha’s bleeding stopped as a result of the many blood-clotting medicines she had been given, but her fever was still raging and she was in tears.

At this point, thinking the worst, I myself raised the spectre of sepsis, and said to a consultant that I was worried Martha would go into septic shock over the bank holiday weekend, when consultants were mostly at home and the ward was eerily quiet. My concerns were dismissed.

Weekends were terrifying on the ward. Most senior doctors don’t tend to work on these days — it is a privilege that goes with their status, but it makes hospitals more perilous. 

The consultants we saw went home after the morning ward round, on call.

On Saturday, Martha got worse. She felt dizzy and her fever remained, but in the afternoon no consultant was present on the ward or — despite her previous bleeding — sufficiently interested in her condition to pay her a visit. 

We were merely told not to worry: ‘infections come and go’.

Then on Sunday morning, she was much worse, with very low blood pressure. Two senior doctors whispered about Martha outside her cubicle, but I, straining to hear, was told nothing.

I found out later that the duty consultant knew she was critically ill with sepsis, but didn’t stay on the ward — he went home, as planned. 

He didn’t draw up a plan for her care, and failed to make it clear that a line into Martha’s arm shouldn’t be used, even though it was a potential source of infection.

Martha had low blood pressure, a fever and a rapid heart rate. She then developed a rash. 

These were all clear signs of a sepsis emergency, but inexplicably, she still wasn’t moved to intensive care, where a bed was available.

Even when her risk metric called for immediate escalation, she wasn’t moved. This was against hospital protocol.

The registrar in charge, who had little or no experience of treating Martha’s injury, somehow managed to conclude that the rash wasn’t caused by sepsis. 

He dismissed my objections and I was told by the nurses to ‘trust the doctors’.

This registrar also failed to call for a blood test that would indicate if the sepsis was getting worse. 

Perhaps most shocking of all, when called at home, the consultant didn’t query the rash misdiagnosis and said ‘categorically’ that a potentially life-saving bedside visit from a member of ICU shouldn’t happen — because it would increase my anxiety.

Again this was directly against hospital guidelines.

If this isn’t enough of a catalogue of horrendous decision-making and complacency, the senior house officer on the ward that night (the only doctor there) didn’t once visit Martha — the most critically ill child in her care — because, as the external investigation told us later, she didn’t think it was her job to look after the ‘sick patients’.

Early on Monday morning, Martha had a seizure. Lying on her bed, she told me she thought her condition was ‘unfixable’: she had been left for so long she knew she was going to die.

Finally, the medics woke up to the situation and arranged for her to be moved to ICU. But it was far too late — Martha was in septic shock and she never recovered.

What upsets me most is that I know the King’s doctors took risks with my child’s life.

They weren’t safe, their actions were full of hubris, and I know for sure that they would never have taken such chances if one of their own children had been in Martha’s place.

The NHS saves innumerable lives, and I have spoken to wonderful medics who are expert at listening and who involve the testimony of patients and families in their diagnoses. We depend on doctors in a crisis and we rely on their expertise.

But as many medics have told me since Martha died, doctors are only human, and some are better than others. There are arrogant ones, brilliant ones, lazy ones, ones who don’t listen.

So any patient who is worried things are going wrong shouldn’t feel intimidated.

And they shouldn’t feel that any conversation ends with ‘doctor knows best’.

I believe in the essential principles of the NHS but there needs to be more conversation about the culture in medicine and in hospitals. 

Many medics have an ‘us and them’ attitude to laypeople, and can be condescending. 

The patient safety campaigner and airline pilot Martin Bromiley points out that there is very little oversight of consultants, who have always wielded immense clout within the NHS.

There needs to be more patient power. I knew so much about Martha’s changing condition. Had I been listened to by the doctors, I could well have saved Martha’s life.

This is why I am calling for ‘Martha’s Rule’, which formalises the right to an urgent second opinion if a patient or family member feels that a deterioration isn’t being addressed on a hospital ward.

The Health Secretary, Steve Barclay, said in the Commons this week he’ll explore its introduction and Wes Streeting, his shadow, has committed Labour to introducing ‘Martha’s Rule’ should they form a government.

The NHS has responded to say that patients can already ask for a second opinion. This is disingenuous. Everybody knows it’s daunting to challenge a medic, especially a swaggering senior doctor.

Patients and their family members often feel powerless in hospital — I know I did — and one means of increasing patient power is a formalised right to a second opinion, with information about how to exercise that right clearly visible on every ward.

Doctors may object that it will be overused, but a form of ‘Martha’s Rule’ exists in other countries and the opposite has proved to be the case.

To argue that such an initiative would be abused is just another way of patronising patients. 

NHS vested interests will put up lots of barriers to ‘Martha’s Rule’, sounding empathetic the whole time, but for the benefit of patients these must be pushed aside.

King’s College Hospital has said they are ‘deeply sorry we failed Martha when she needed us most’. 

They have put basic policies in place following her death, for instance compulsory sepsis training, adequate recognition of parental concern, and an outreach service involving paediatric ICU.

But each measure already existed in many other hospitals, which raises the question: why did Martha have to die for these changes to be made at King’s?

Who is answerable?

I shall never be able to forgive the hospital, but I can at least work for something good to emerge from this nightmare.

Martha’s 16th birthday was a few days ago and I wonder what presents she would have asked for. But she is frozen in time. 

Unlike her friends, she hasn’t just begun the new school year, and isn’t coming home with the gossip or stories about her day.

My life now has a void at its centre. Instead of listening to Martha telling me her plans, instead of seeing her sitting close to her sister, instead of cooking and caring for her, all I can do is put flowers on her bench in our local park — and desperately wish she was still with me every day.

• The fee for this article will be donated to the UK Sepsis Trust. If you wish to donate please go to sepsistrust.org or to Slow, a group for bereaved parents slowgroup.co.uk