Martha Mills

fi!1:kj 

King's College Hospital 
NHS Foundation Trust 

Chief Executive 
King's College Hospital 
Denmark Hill 
London SES 9RS 

www.kch.nhs.net 

21 April 2022 

Private and Confidential 

Coroner ME Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner's Court 
Carnley Street 
London 
N1C4PP 

Dear Madam 

I am writing to you in response to the regulation 28 report made following the inquest into 
the death of Martha Mills on the 25th  February 2022.  I would like to thank you for bringing 
your concerns to my attention. This is a truly saddening case, and one that I have been 
briefed on by the Chief Nurse regularly.  I can only imagine how difficult this has been for 
Martha's family, and I am sure that they also welcome your intervention and insights in 
ensuring we learn from her death. 

This has been an incredibly sad  case, and one in which we have recognised from an  early 
stage that there were things which we could and should have done differently to give 
Martha the best opportunity to recover from this injury.  I am truly sorry for the mistakes 
that were made. 

We had undertaken a serious incident investigation following Martha's death that identified 
a number of causal and contributory factors which we agreed needed to be addressed to 
improve safety. The action plan to address these was included in the Serious Incident 
investigation report which was shared during the inquest. I note that your report asks us to 
take further steps, so I have included an  updated position in relation to the serious incident 
action plan in addition to outlining the steps to address your findings. This is to ensure that 
our proposed actions are understood in context, and also to offer you and Martha's family 
assurance that we are taking the steps which are needed to prevent this happening again. 

Serious Incident Finding 1 

-

Sub-optimal interface between Paediatric Hepatology and Critical Care services. 

Action Proposed 
Establish regular meetings between Rays 
of Sunshine ward and other paediatric 
wards and PICU to review all referrals 

Update 
A safety huddle has now been established 
which includes review of all referrals, lessons 
learnt and actions taken. This also supports 

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 between the services, lessons learnt, and 
actions taken 

increased face to face contact between the 
paediatric wards. 

Seek to fully fund a Paediatric Critical Care 
Outreach  service to bring the paediatric 
service into alignment with adult critical 
services  at KCH through submission of a 
business case 

The business case for an outreach team has 
been written and submitted, and is due to be 
considered by the Trust's Investment Board 
in May 2022. 

The t able set out above relate to the actions in the serious incident report.  In your report 
you explained that: 

'You had heard evidence that the intention of King's to improve the formal relationship 
between the hepatology and the paediatric intensive care departments, and to ensure that 
there is pro-active paediatric intensive care outreach. However, the intended programme 
has stalled, I think partly because of the pandemic. It seems that there needs to be an 
impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the 
future.' 

Therefore the additional actions have also been initiated: 

•  Following M artha's death it was agreed that the escalation process (previous version 

2016) needed to be refined and formalised through a standardised operating 

protocol (SOP) for children requiring critical care. This includes the internal 

escalation pathway for children requirin g critical care specifying when childre n 
should be escalated. This ensures that there is a standardised approach to 
escalation, rather than reliance on individual clinician decision making.  Any member 

of the clinical team can  refer to critical care for advice where a child meets the 
criteria recommended in the SOP. The SOP is currently being reviewed and signed off 

through the Child  Health Governance processes and the current draft is enclosed. 
This is due to be approved in May 2022. 

•  A weekly group has been set up consisting of the Children's Health Senior Leadership 

Team, Site Medical Director, Director of Quality Governance and an Organisational 

Development expert to ensure that there is focus and momentum in implementing 

the action plans. 

•  An organisational development expert has been identified to work alongside the 

Children's Health Senior Leadership team to develop a bespoke package that will 

help to enhance effective clinical relationships between hepatology and the 

paediatric intensive care departments. The package consists of three stages which 
will help the teams to explore and build better relationships in relation t o 
collaboration, communications and conflict. 

• 

Improving the care of deteriorating patients, specifically including paediatric 

patients, has been agreed as one of the Trust's 4 Quality Priorities for 2022/23. This 

means that the improvement work will be subject to enhanced scrutiny at Executive 
and Non-Executive level to support momentum. 

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 Serious Incident Finding 2 

High thresholds for Paediatric Critical Care review of children with evolving severe 
illness on ROSW 

Action Proposed 
Review current VCH  policy for escalation 

processes for junior medical staff and 
nursing staff 

Emphasise on the importance of parental 
concern as a trigger for early review by 

improving the education and training for 
the use ofthe parental concerns tool the 

SPEWS chart. 

Update 

The escalation policy has been revised and 
finalised and is currently proceeding through 
governance sign off processes and is due to 
be signed off in May 2022. 
The wording of the parental concern trigger 
has now been agreed, and this is being 
incorporated into the electronic PEWS. 

The table set out above relates to the a~ions arising from the serious incident investigation. 
In your report you explained that: 

'I heard that the bedside paediatric early warning score (BPEWS) system at King's is currently 
still paper based, unlike the adult system. 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 ofsituation recurring.' 

At the current time there is no nationally agreed early warning score for children as 
discussions involving the Royal College of Paediatrics and  Child Health (RCPCH) and NHS 
England have yet to provide a consensus agreement on what form this should take.  This 
means that the commercially available electronic PEWS systems are limited and therefore 
most hospitals depend largely on the customisation of in-house clinical IT systems according 
to the decision of the local teams.  The Bedside PEWS (SPEWS) is the early warning system 
that the paediatric team at KCH  have chosen to use in the absence of specific national 
direction on the matter. 

The Trust has very recently committed to the implementation of a fully integrated electronic 
patient record system (Epic) which will replace the vast majority of  existing clinical IT 
systems in late 2023 and will provide a customised early warning score for paediatrics. 
However as an  interim measure, with support from our in-house clinical IT support teams, 
we have now developed a way of capturing paediatric early warning scores on our existing 
electronic system. This will support clinical teams to capture all relevant observations, 
highlight patients at risk (to those at the bedside and those monitoring the wards overall), 
and ensure that the team can document what has been done to treat/escalate based on the 
score. 

Serious Incident Finding 3 & 4 

Insensitivity of BPEWS alone for identifying deteriorating children. 

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 Reliance upon systolic blood pressure as a marker of cardiovascular dysfunction in children 

Action Proposed 

Update 

Review current VCH  policy for escalation 

processes for junior medical staff and 

The escalation policy has been revised and 
finalised and is currently proceeding through 

nursing staff 

Review and improve medical and nursing 
training on  BPEWS, escalation and 
outreach. 

governance sign off processes and this is due 
to be signed off in May 2022. 

Nurses and medical staff receive PEWs 
training on induction and nurse education 
team have been spot checking nursing staff 
assessment, documentation and action 
taken on observations. Where any gaps are 
identified in practice, a re-training package is 
put in place. PEWS training is  also included in 
regular recall training. All student nurses 
receive training in PEWs each year including 
initial induction and the n refresher sessions 
for each year of training. 

The sepsis training has now been made 
mandatory for paediatric staff. The Health 
Education England module on paediatric 
sepsis is being integrated into the Trust's 
learning and education platform (LEAP) to 
ensure that training compliance can be 

monitored. It is anticipated that this will be 
completed by May 2022. 

Deterioration Patient training (Deteriorating 
Child on the Ward - how, when an who to 
escalate?) is now included in the PICU 

teaching lecture attended by all child health 
trainees. This commenced in March 2022, 
and the session will be delivered biannually 
going forward (March and September each 
year). 

Further training is being developed to 
support roll out of electronic PEWS, which 
include the parental concern trigger. The 
education team are part of the working 
group and will be supporting the roll out in 
June. 

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 Introduce scenario tool kit as mandatory 

for all child health NIC and junior doctor 

staff 

STPN  scenario tool kit is now mandatory for 
all child health nurse in charge and junior 
doctor staff. It is being incorporated into 
simulation days recommencing in May 2022 

Serious Incident Finding 5 
- Restricted medical process for escalation to critical care review. 

Action Proposed 

Update 

Seek to fully fund a Paediatric Critical Care 

The business case for an outreach team has 

Outreach  service to bring the paediatric 

been written and submitted, and is due to be 

service into alignment with adult critical 

considered by the Trust's Investment Board 

services  at KCH  through submission of a 

in Ql 2022/23 

business case 

Serious Incident Finding 5 
- Complex underlying and incompletely characterised acute illness driving deterioration. 

Update 

This was completed in October 2021 

Consultant of week for surgery and 
hepatology on the day of admission will have 
named joint responsibility for the patient. 
The clinical ownership will still change week 
to week with the consultant of the week, 
which is standard practice for all long term 
patients. 
Regular weekly multi-disciplinary team 
(MDT) meetings are in place to ensure good 
communication and handover. 
This work is in progress and is expected to 
conclude in summer 2022. 

Meeting took place with Evelina hospital in 
April 2022 to progress paediatric cardiac 
service collaboration. This work is on course 
for completion by the end of 2022. 

Action Proposed 

M&M case review 

Assign  a  'Named  Consultant'  with  overall 
responsibility  for  decision  making  and 
definitive  communication 
in  pancreatic 
trauma cases 

Development  of  patient  and  next-of  kin 
information  resources  to  support  them 
through admission with pancreatic trauma 

an 

on-site 

paediatric 

Develop 
echocardiography service: 
- Formalise pathway for rapid escalation for 
paediatric echocardiography involving the 
Evelina  and  the  on-site  adult  cardiology 
teams dependent upon age 
- Train on-site technician service to 
undertake paediatric echocardiography 
and supplement the service from the 
Evelina 

Monitoring of ongoing actions 

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 The Trust, and all of those involved in Martha's care, are very sorry for what has happened. 
We understand that there were failings in our systems and processes to protect Martha, and 
we are committed to ensuring that there is lasting organisational change as a result.  To 
ensure that this is the case, the actions outlined in this document will be overseen in the 
following way: 

•  Regular task and finish group meetings to support action plan implementation 

•  There will be an audit of the escalation SOP at 3 months post implementation and 

then at agreed intervals. Results will be reported through to the Children and Young 
People's Board which is chaired by the Chief  Nurse. 

•  The organisational development plan will be kept under review through oversight of 

outcomes at each stage. 

•  Update on overall progress against the defined actions will be monitored through 
the Serious Incident Committee, and overseen by the Patient Safety Committee 
which is chaired by the Medical Director. 

•  Assurance will be provided to the Quality, People and Performance Committee on 

the completion and impact of the actions taken, which is chaired by a Non-Executive 
Director. 

•  The Care Quality Commission will be updated regularly as part of relationship 

management meetings. 

The Trust is always willing to provide Martha's family with regular updates on the progress 
that has been made. 

Yours sincerely 

Chief Executive 

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