The NHS is failing to appropriately diagnose and treat children with infections, a coroner has warned, after a nine-year-old girl died in a case with “striking similarities” to Martha Mills.
Mary Hassell, senior coroner for inner north London, has written to Steve Barclay, the Health Secretary, and NHS England, warning of a “fundamental issue” in care which saw both Martha and Riya Hirani pass away with conditions that were preventable.
Riya, nine, died in December 2022 after suffering a cardiac arrest a day after being sent home with over-the-counter painkillers for a “sore throat”, despite her mother, Geeta Hirani, correctly identifying a streptococcus (Strep A) infection during a publicised outbreak.
Mrs Hirani questioned the junior doctor’s diagnosis and was convinced her daughter was “extremely ill”, but was sent home only for Riya to suffer a “fatal collapse” one day later.
The coroner said there were “striking similarities” in the treatment of both Riya and Martha, after both died due to doctors failing to identify infections and listen to parents’ concerns.
Martha died aged 13 in August 2021 after doctors at King’s College Hospital, London, failed to identify sepsis – despite her parents repeatedly raising concerns their child’s condition was deteriorating.
Her mother, Merope Mills, has been campaigning for the introduction of “Martha’s Rule”, which would see patients or their parents legally entitled to a second opinion.
“Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills,” Mrs Hassell wrote in a prevention of future deaths report.
“On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care.”
Regarding the proposed introduction of Martha’s Rule, she said it was important for Mr Barclay “to be aware of the circumstances of Riya’s death before you decide how to proceed”.
Mrs Hassell’s report into Riya’s death found that “there was a consultant available to give a second opinion if this had been requested by medical personnel” but “no thought was given to it”.
“I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation,” she concluded.
Mr Barclay has said the Government is committed to bringing in “Martha’s Rule” and health officials were working “at pace” to introduce a system across hospitals.
Mrs Hassell added that “there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.”
“In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action,” she concluded.
A response is required by 13 Nov 2023.
An NHS spokesperson said: “All patients and families are able to seek a second opinion if they have concerns about their care - and, as professional guidance for doctors in England sets out, it is essential that any patient’s wishes to seek a second opinion are respected.
“The NHS is already taking steps to ensure patients and families can more easily speak up about how they feel and escalate their concerns about their illness, with seven pilot sites across the country looking at the work of Royal Berkshire who have a system which enables patients and families to immediately seek advice if they believe their loved one’s condition has changed.”