(As told by Martha’s mother Merope)

We were on a holiday in Snowden in Wales. I got the last cottage in a beautiful place on the top of a hill that was full of sheep. We were having a lovely time. Martha and I painted the view.

On the second day, we went for a bike ride. On the way back, Martha was cycling behind us, skidded and the handlebars went into her stomach. When she lifted her t-shirt, there was this round, red ring imprint.  At first, we just thought she was winded, but she didn’t seem to be feeling better, so we took her to a minor injuries unit. There the nurse described her injury on the phone to a doctor who said it wasn’t necessary to see Martha and prescribed paracetamol.

I wondered whether to insist that she was seen but I didn’t, and we returned to the cottage. However, by 2am, Martha was sick and in pain, so we thought ‘Okay, this is serious, we need the emergency room.’

She was in so much pain that she couldn’t even walk so my husband Paul had to push her to the car in this wheelbarrow. At the hospital, they did some tests and the doctor said, ‘It’s pancreatic trauma. We need to act quickly.’

There are only three places in the country that treat pancreatic trauma in children, and the one closest to us in London was King’s College Hospital. That was where Martha would live and die over the following month.

Initially, I cannot tell you how relieved I was to be there. We got to this particular ward that looked after children with pancreatic injury, called Rays of Sunshine, and I subsequently learnt that it was described as a centre of excellence.

For a long period of time, it felt like Martha was getting better. Her friends came to visit, she played Minecraft with them on their phones, we watched movies in the evening. She was bored, she couldn’t eat, so she was being fed with a tube down her nose.

But after about four and a half weeks, she developed an infection. They couldn’t trace the source of it, and the antibiotics they gave her didn’t seem to be working. After about four or five days, she suddenly started to bleed unexpectedly out of a line in her arm and tube in her abdomen. I know now that this is called a disseminated intravascular coagulation (DIC) and it is a sign of severe sepsis.

Not once did the doctors mention the word sepsis, only infection. I feel this was deliberate. We were just told it was a normal side effect of infection. Nothing to worry about. Instead they said her clotting abilities were slightly off, and the doctors gave her lots of clotting products.

The bleeding stopped but then Martha got a rash, which even I knew was a red flag for sepsis. Instead, the doctor said he was quite convinced it was an allergic reaction to one of the antibiotics and arranged for the dermatologist to come and see her.

At this point, it was the Friday before the bank holiday weekend and I said to the consultant, ‘I’m worried she’s going to go into sepsis shock, and none of you will be here.’ She said, ‘I know what you mean, but I’m not worried about sepsis, it’s just a normal infection.’

The next day, a different consultant was there. This was one of the problems, the consultants changed all the time. Martha was passed like a baton from one to the next, none of them seeing her deterioration over the course of the weekend. They were worried about her, but not enough to leave any sort of direction for the junior doctors if she deteriorated.

At five in the morning, she had a huge seizure. A blood test showed that she had sepsis, and she was finally taken to pediatric ICU. I watched her be put into a coma, and a day later, she was dead.

The most shocking thing was the extent to which we had been kept in the dark by the doctors. We felt that was deliberate, that we were patronised and managed, given limited information. Misogyny played a part in it –  one consultant said that Martha should not have a critical care review from the pediatric ICU because it would only increase my anxiety. I think that that review could have saved her life.

Ego played a huge part. A number of the consultants on Rays of Sunshine were on a higher level than some of the paediatric ICU doctors, and they felt they didn’t need to go to them for advice. But good doctors should welcome a second opinion.

With Martha’s rule, we want to effectively formalize a second opinion within a hospital when patients and family members are worried. The Coroner’s Court ruled that Martha would still be alive if she had been moved sooner to paediatric ICU where she would have had different care.