NHS bosses have called for an urgent review of sepsis care at a London hospital after a baby died following delays in treatment, the Standard can reveal.
Martyn Mirchev, aged 11 months old, died on May 16 last year just six hours after being re-admitted to Kingston hospital.
He had been sent home from the same hospital on May 2 and doctors were awaiting test results from a throat swab after his parents noticed he had developed a fever and was vomiting. A consultant decided against prescribing antibiotics pending the result of the swab test.
The results of his test were chased by a nurse practitioner eight days later, but the laboratory said they had not received them.
By his second admission to hospital he had contracted the infection Group A strep and sepsis, a fatal condition which causes the body to attack itself in response to an infection.
Martyn’s parents, Veni and Deyan, have spoken out for the first time since his death and paid tribute to their “amazing little boy”.
Ms Mirchev, 35, told the Standard: “When we heard nothing from the hospital about his swab we took him to the GP. When they told us to take Martyn to hospital we never imagined that in a few hours he would have passed away.
“That afternoon will remain with us forever and is something I don’t think our family will get over. Seeing Martyn as his condition deteriorated so quickly was awful. As his mum, all I wanted to do was care for him and help him, but I felt so powerless.”
She added: “Martyn was the most amazing little boy. His sisters adored him and it remains hard to think that he should still be at home with us all.
“He was just an absolute delight and didn’t deserve to die.”
An investigation report conducted by the Trust, dated November 2023, found that previous cases had highlighted concerns regarding the identification and treatment of sepsis in children attending the emergency department.
Previous recommendations had “not been wholly effective in preventing” Martyn’s death, the report added.
It also identified a number of problems with Martyn’s care, including:
- Gaps in sepsis care knowledge led to a delay in recognising red flag symptoms, use of sepsis screening and when to start sepsis six care.
- Incomplete medical observation of Martyn when he arrived at hospital on 16 May.
- Inaccurate handover of Martyn’s condition between staff
- There was a “missed opportunity” to follow up the missing swab taken on May 2. The Trust said it was usually standard practice to chase swab results within three working days but there was no evidence this happened until May 10.
The report said it was “feasible” that when Martyn was taken to hospital on May 2, the infection could have been Group A strep. However, it was impossible to know without the throat swab result.
Martyn may have survived with earlier treatment but investigators were unable to conclude this with certainty, the report said.
It added that “immediate actions must be taken to ensure the safety of children attending the emergency department now, to prevent avoidable deaths from sepsis”.
Mr Mirchev said: “While we want answers for our boy, we also want others who may be affected by similar care issues at the Hospital Trust to be aware and for improvements in care to be made. We wouldn’t want anyone to have face the hurt and pain our family are now left to live with.”
Emergency staff failed to recognise and act on abnormal and incomplete observations during an initial assessment, according to the incident investigation report.
The report said that Martyn should have remained in the emergency department and started “sepsis six” treatment – a key set of medical interventions including intravenous antibiotics and fluids that must be started within an hour of suspected sepsis.
Instead, he was transferred to the paediatric assessment unit around 40 minutes after he arrived at hospital.
Martyn did not start receiving treatment for sepsis until nearly two-and-a-half hours after arriving at hospital. He died later that afternoon.
An inquest examining the circumstances of Martyn’s death is expected to be held at a later date.
His family are being supported by lawyers from Irwin Mitchell.
Alexandra Roberts, the medical negligence expert at Irwin Mitchell representing Martyn’s loved ones, said: “While we welcome the Trust’s review, it is now vital that the most comprehensive investigation is conducted. Staff need to be made fully aware of its findings and must be supported to ensure the highest standard of care is upheld at all times so other lives are not put at risk.”
The family have also urged parents and the public to look out for signs of sepsis, which include slurred speech, confusion, extreme shivering and muscle pain, passing no urine in a day, severe breathlessness and mottled or discoloured skin.
A spokesperson for Kingston Hospital NHS Trust said: “We offer our sincere condolences to the family on the death of their son. Our investigation identified that there were problems with the care we provided and we are deeply sorry for these.
“We are committed to improving the care of children with sepsis. Immediate action has been taken to ensure the safety of patients and we recognise the importance of continuing to progress this vital work.”
