Family And Medical Negligence Lawyers Issue Sepsis Warning Following Surbiton Boy's Death

Health bosses have called for an urgent review of sepsis care in children at a London Hospital Trust after a baby died following treatment delays. 

Kingston Hospital NHS Foundation Trust has recommended a “deep dive” review in the paediatric emergency department following Martyn Mirchev’s death. 

The 11-month-old died on 16 May 2023, around six hours after being re-admitted to Kingston Hospital in southwest London. On 2 May 2023, he was sent home from hospital without antibiotics and awaiting the results of a throat swab – which later went missing – after his parents were concerned he had a fever and was vomiting.

Martyn contracted Group A strep and sepsis

By his second admission to hospital he had contracted the infection Group A strep and sepsis – which sees the body attack itself in response to an infection. 

During an initial assessment, emergency staff failed to recognise and act on abnormal and incomplete observations, a serious incident investigation report by the Hospital Trust, and seen by expert medical negligence lawyers at Irwin Mitchell, said. 

There was a delay in recognising and treating sepsis. Martyn should have remained in the emergency department and started ‘sepsis six’ treatment - a key set of medical interventions including, intravenous antibiotics and fluids and to be started within an hour of suspected sepsis - the report added. Instead, a decision was made to transfer him to a paediatric assessment unit around 40 minutes after he arrived at hospital. 

Baby didn't receive sepsis treatment until nearly two-and-a-half hours after arriving at London's Kingston 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.

The investigation report found 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 dated November 2023 added. 

The recommended review should look at why the sepsis six tool had not been effectively used. 

Medical negligence lawyers and Martyn's family issue sepsis warning after investigation calls for immediate action to prevent avoidable deaths 

While a review was carried out “immediate actions must be taken to ensure the safety of children attending the emergency department now, to prevent avoidable deaths from sepsis,” the report added. 

Martyn’s parents, Veni and Deyan, aged 35 and 36, of Surbiton, Surrey, have spoken for the first time about their devastating loss. They have joined their legal team at Irwin Mitchell in warning of the dangers of sepsis and the need for more awareness around its symptoms. 

Expert Opinion

“Sepsis is an incredibly serious condition and can have devastating consequences for patients and their families. Therefore, early detection and treatment are key to beating it. Every minute counts and can make the difference between life and death.

“Sadly, the Hospital Trust’s own investigation has found worrying areas in the care Martyn received. While those are incredibly concerning, what’s even more disturbing is that Martyn’s death appears to have followed previous sepsis care incidents after which lessons seemingly haven’t been learned, nor recommendations to ensure patient safety upheld.

“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.” Alexandra Roberts

Investigation finds problems in Martyn Mirchev's care

The Hospital Trust’s investigation report found a number of care problems 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 2 May. The Trust said it was usually standard practice to chase swab results within three working days but there was no evidence this happened until 10 May.

The report said it was “feasible” that when Martyn was taken to hospital on 2 May, the infection could have been Group A strep. However, it was impossible to know without the throat swab result. 

It was possible that Martyn may have survived with earlier treatment, but investigators were unable to conclude this with any certainty. 

An inquest examining the circumstances of Martyn’s death is now expected to be held at a later date.

Expert Opinion

“Understandably Martyn’s loved ones continue to have many concerns about Martyn’s death and we are supporting them so they can at least receive all of the answers they deserve.

“In the meantime, we join Veni and Deyan in urging everyone to be aware of the signs of sepsis. While the Hospital Trust’s report has identified issues, it is vital people continue to seek medical advice as soon as possible if they suspect they or a loved one has sepsis.” Alexandra Roberts

Martyn's parents pay tribute to "amazing little boy" as they call for improved care

Veni said: “After being sent home from hospital, Martyn didn’t seem his usual happy self and we remained concerned about him. 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.

“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.”

Deyan added: “It was hard enough to read the problems in Martyn’s care in the report. However, to see that there appears to have been previous incidents and that care issues were continuing is astonishing for all the wrong reasons. 

“My heart immediately went out to others who may also be affected. We’re now left wondering how many other incidents have there been and are the other families even aware? 

“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.”

Signs of sepsis

Signs of sepsis include slurred speech, confusion, extreme shivering and muscle pain, passing no urine in a day, severe breathlessness and mottled or discoloured skin. 

For more information about sepsis visit the UK Sepsis Trust's website.

Find out more about Irwin Mitchell's expertise un supporting families affected by sepsis and other care issues at our dedicated medical negligence section. Alternatively, to speak to an expert contact us or call 0370 1500 100. 

Martyn Mirchev: Background

Martyn, who lived with his parents, sisters Ivon and Nicole, aged 16 and four, and grandma, Roza aged 58, was taken to Kingston Hospital on 2 May, 2022, suffering from vomiting and a fever. Following an examination, a throat swab was taken and he was allowed home. A consultant decided against prescribing antibiotics pending the result of the throat swab, the investigation report said.

On 10 May a nurse practitioner chased the swab results but the testing laboratory said it hadn’t received it. 

At around 11.30am on 16 May, 2022, Martyn and his mum returned to hospital after being referred by a GP concerned he had a rash and a fever.

Martyn was seen by a nurse and found to have a high heart rate. However, they were unable to check his blood pressure. The nurse incorrectly calculated his condition as ‘normal’ as on the Paediatric Early Warning Score (PEWS) - a system that helps to identify children at increased risk of deterioration. 

When the results were put on the computer system, the system will have suggested staff carried out sepsis screening because Martyn’s blood pressure had not been taken. However, this wasn’t acted upon, the report found.

Had sepsis screening been undertaken, Martyn would have been referred to a senior doctor or nurse because of the “red flags” of his rash and abnormal PEWS to decide whether treatment for the condition needed to start, the report said.

Instead of remaining in the emergency department, Martyn was transferred to the paediatric assessment unit, arriving at 12.30pm. 
 
Following another assessment at around 12.45pm, sepsis screening was not carried out for a second time. 

It was only after another assessment by a registrar and concerns about Martyn’s rash that sepsis screening started with Martyn starting treatment at 2pm – approaching two-and-a-half hours after he was admitted, the report found. 

However, Martyn’s condition rapidly deteriorated. He suffered a cardiac arrest and died at around 5.45pm.