PFD report

Martha Poppy MILLS · Prevention of Future Deaths report

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Issued 28 Feb 2022•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
22

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to provide an electronic paediatric early warning score and recording system
    Part of recurring concern: Unreliable clinical Early Warning Score systems for deterioration
  2. Failure to maintain an effective formal relationship between paediatric hepatology and paediatric intensive care
    Part of recurring concern: Failure to provide continuity of patient carePart of recurring concern: Unreliable inter-specialty communication for complex patient care
  3. Failure to provide proactive paediatric intensive care outreach
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Develop and support training for rollout of electronic paediatric early warning scores, including the parental-concern trigger.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  2. Action

    Implement the fully integrated Epic electronic patient record with a customised paediatric early warning score.

    Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 March 2022.
  3. Action

    Implement interim electronic capture of paediatric early warning scores on the existing clinical system.

    Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 March 2022.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide an electronic paediatric early warning score and recording system

Wider context from the report

“1. 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 of situation recurring. ”

Is this part of a recurring concern?

Yes — Unreliable clinical Early Warning Score systems for deterioration.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain an effective formal relationship between paediatric hepatology and paediatric intensive care

Wider context from the report

“2. The King’s serious incident investigation identified that Martha’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 an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of patient care; Unreliable inter-specialty communication for complex patient care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide proactive paediatric intensive care outreach

Wider context from the report

“2. The King’s serious incident investigation identified that Martha’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 an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and support training for rollout of electronic paediatric early warning scores, including the parental-concern trigger.

Verbatim wording from the response

“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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 4 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the fully integrated Epic electronic patient record with a customised paediatric early warning score.

Verbatim wording from the response

“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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 3 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement interim electronic capture of paediatric early warning scores on the existing clinical system.

Verbatim wording from the response

“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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 3 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a bespoke organisational-development package to improve collaboration, communication and conflict management between hepatology and paediatric intensive care.

Verbatim wording from the response

“• 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 to collaboration, communications and conflict.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 2 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Submit a business case for a paediatric critical care outreach team for Investment Board consideration.

Verbatim wording from the response

“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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 2 · response
Published 3 March 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.17

  1. 1

    Make paediatric sepsis training mandatory and integrate the Health Education England module into the learning platform for compliance monitoring.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  2. 2

    Audit the escalation protocol three months after implementation and at subsequent agreed intervals, reporting results through the Children and Young People’s Board.

    Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 March 2022.
  3. 3

    Run a weekly senior leadership group to maintain focus and momentum in implementing action plans.

    Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2022.
  4. 4

    Provide paediatric early warning score training, induction, refresher education, spot checks and remedial retraining for relevant staff.

    Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2022.
  5. 5

    Incorporate an agreed parental-concern trigger into the electronic paediatric early warning score.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  6. 6

    Revise and obtain governance approval for the escalation policy governing junior medical and nursing staff.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  7. 7

    Run regular task-and-finish group meetings supporting action-plan implementation.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  8. 8

    Develop an on-site paediatric echocardiography service with rapid escalation pathways, technician training and Evelina support.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  9. 9

    Complete multidisciplinary morbidity-and-mortality review of the relevant case.

    Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2022.
  10. 10

    Operate safety huddles reviewing referrals, lessons learned and actions across paediatric wards and PICU.

    Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2022.
  11. 11

    Develop and obtain approval for a standardised operating protocol defining escalation criteria and pathways for children requiring critical care.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  12. 12

    Monitor action-plan progress and provide committee assurance on completion and impact through Trust safety and governance committees.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  13. 13

    Provide regular Care Quality Commission updates through relationship-management meetings.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  14. 14

    Make improving care of deteriorating patients, including paediatric patients, a 2022/23 Trust quality priority with enhanced executive scrutiny.

    Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2022.
  15. 15

    Develop patient and next-of-kin information resources for admissions involving pancreatic trauma.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  16. 16

    Deliver biannual deteriorating-child escalation training to all child health trainees through PICU teaching.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
  17. 17

    Make the STPN scenario toolkit mandatory for child health nurses in charge and junior doctors and incorporate it into simulation days.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    A fixed named consultant is not adopted because rotating consultant responsibility and weekly multidisciplinary meetings are considered sufficient for ownership and communication.

    Stated by King'S College Hospital NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Make paediatric sepsis training mandatory and integrate the Health Education England module into the learning platform for compliance monitoring.

Verbatim wording from the response

“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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 4 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit the escalation protocol three months after implementation and at subsequent agreed intervals, reporting results through the Children and Young People’s Board.

Verbatim wording from the response

“• 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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 6 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Run a weekly senior leadership group to maintain focus and momentum in implementing action plans.

Verbatim wording from the response

“• 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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 2 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide paediatric early warning score training, induction, refresher education, spot checks and remedial retraining for relevant staff.

Verbatim wording from the response

“Review and improve medical and nursing training on BPEWS, escalation and outreach. | 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 then refresher sessions for each year of training.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 4 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Incorporate an agreed parental-concern trigger into the electronic paediatric early warning score.

Verbatim wording from the response

“Emphasise on the importance of parental concern as a trigger for early review by improving the education and training for the use of the parental concerns tool the BPEWS chart. | The wording of the parental concern trigger has now been agreed, and this is being incorporated into the electronic PEWS.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 3 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Revise and obtain governance approval for the escalation policy governing junior medical and nursing staff.

Verbatim wording from the response

“Action Proposed | Update Review current VCH policy for escalation processes for junior medical staff and nursing staff | 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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 3 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Run regular task-and-finish group meetings supporting action-plan implementation.

Verbatim wording from the response

“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:”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 6 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop an on-site paediatric echocardiography service with rapid escalation pathways, technician training and Evelina support.

Verbatim wording from the response

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

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 5 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete multidisciplinary morbidity-and-mortality review of the relevant case.

Verbatim wording from the response

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

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 5 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate safety huddles reviewing referrals, lessons learned and actions across paediatric wards and PICU.

Verbatim wording from the response

“Action Proposed | Update Establish regular meetings between Rays of Sunshine ward and other paediatric wards and PICU to review all referrals | A safety huddle has now been established which includes review of all referrals, lessons learnt and actions taken. This also supports”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 1 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and obtain approval for a standardised operating protocol defining escalation criteria and pathways for children requiring critical care.

Verbatim wording from the response

“• Following Martha’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 requiring critical care specifying when children 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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 2 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitor action-plan progress and provide committee assurance on completion and impact through Trust safety and governance committees.

Verbatim wording from the response

“• 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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 6 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide regular Care Quality Commission updates through relationship-management meetings.

Verbatim wording from the response

“• The Care Quality Commission will be updated regularly as part of relationship management meetings.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 6 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Make improving care of deteriorating patients, including paediatric patients, a 2022/23 Trust quality priority with enhanced executive scrutiny.

Verbatim wording from the response

“• 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.”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 2 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop patient and next-of-kin information resources for admissions involving pancreatic trauma.

Verbatim wording from the response

“Action Proposed: Development of patient and next-of-kin information resources to support them through admission with pancreatic trauma”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 5 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver biannual deteriorating-child escalation training to all child health trainees through PICU teaching.

Verbatim wording from the response

“Deterioration Patient training (Deteriorating Child on the Ward – how, when and 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).”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 4 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Make the STPN scenario toolkit mandatory for child health nurses in charge and junior doctors and incorporate it into simulation days.

Verbatim wording from the response

“Introduce scenario tool kit as mandatory for all child health NIC and junior doctor staff”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 5 · response
Published 3 March 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

A fixed named consultant is not adopted because rotating consultant responsibility and weekly multidisciplinary meetings are considered sufficient for ownership and communication.

Verbatim wording from the response

“Action Proposed: Assign a ‘Named Consultant’ with overall responsibility for decision making and definitive communication in pancreatic trauma cases”

Source location

2022-0063-Response-from-Kings-College-Hospital_Published
Page 5 · response
Published 3 March 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026