Martha Mills

“whilst at King's [the deceased] was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries.”

“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 of situation recurring.”

“The King's serious incident investigation identified that [the deceased]'s care fell down between the paediatric hepatologists and the paediatric intensivists. I heard evidence that it is 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”