Doctor who failed to spot girl, 13, was suffering from sepsis and died days later will face no disciplinary sanction
Professor Richard Thompson did not refer Martha Mills to intensive care at King's College Hospital in London despite her displaying several high-risk indicators of the life-threatening condition.
The on-call consultant also chose not to return to the hospital to assess her in person as her condition deteriorated.
A Medical Practitioners Tribunal Service (MPTS) panel sitting in Manchester had ruled those omissions were misconduct, which they described as 'particularly grave', and found his fitness to practise was impaired.
But today the tribunal decided there were 'exceptional circumstances' which justified taking no further action against the world-renowned paediatric liver specialist.
Martha had been an inpatient on the hospital's Rays of Sunshine Ward after she suffered a serious injury to her pancreas when she slipped while riding a bike on a family holiday in Wales in July 2021.
Weeks later she experienced a fever and increased heart rate, followed by more spikes in her temperature before the consultant hepatologist saw Martha on his morning ward round on Sunday August 29.
Prof Thompson left the hospital at 3pm, but was phoned at home two hours later by a trainee doctor, who gave an update on Martha's condition.
Medical records showed she had deteriorated over the course of the afternoon, and into the early evening, with a drop in her blood pressure, the appearance of a new rash and increases in heart rate, respiratory rate and body temperature.
Tribunal chairman Robin Ince noted that by 5pm there were 'several high-risk indicators' as set out in the Nice guidelines relating to sepsis.
The duty registrar called Prof Thompson again at 8.30pm because of ongoing concerns over Martha's fever, but she was kept on the ward despite the continued presence of moderate to high-risk indicators and the absence of meaningful clinical improvement.
Martha collapsed on August 30 and was moved to intensive care before she was transferred to London's Great Ormond Street Hospital, where she died in the early hours of August 31.
Announcing its conclusions on Wednesday, Mr Ince said: 'Professor Thompson has done everything possible to address his failings.
'The tribunal considered that the best way to repair any harm caused by his failings would be for him to continue to provide his specialist expertise at home and abroad.
'To now - some four years after the index event - remove Professor Thompson from practice, even for a short period of time, for one single lapse of judgment in an otherwise exemplary career would, in the tribunal's view, be akin to punishment which is not the role of the MPTS.'
Among the 'exceptional circumstances' cited were that there was no allegation or evidence that Prof Thompson either caused or contributed to Martha's death.
There were also systemic failings regarding how the ward functioned at the time with regard to referrals to the paediatric intensive care unit, said the tribunal.
Mr Ince said: 'A sufficiently clear message has already been sent to the profession and to the public - that even such an experienced doctor as Professor Thompson could still make serious errors of clinical judgment for which he will be called to account.
'The public would be aware that this finding would remain a stain on Professor Thompson's reputation for the rest of his life.'
At a 2022 inquest into her death, a coroner ruled that Martha would most likely have survived if doctors had identified the warning signs and transferred her to intensive care earlier.
Martha's mother, Merope Mills, said she and her husband, Paul Laity, raised concerns about Martha's deteriorating health a number of times but these were not acted on.
The couple later successfully campaigned for Martha's Rule to give patients, families and carers the chance to easily request a second opinion from a senior doctor in the same hospital in the event of a suspected deterioration or serious concern.
Giving evidence, Prof Thompson told the MPTS hearing that he no longer provided in-patient care because he began to 'doubt my own judgment' after the tragic events.
He said he felt 'deep remorse' for Martha's death but did not believe he made any errors in her case, as he denied all the allegations brought by the General Medical Council (GMC).
The tribunal heard he had since completed a training course relating to the management of sepsis and a deteriorating child in paediatric care.
His barrister, Ben Rich, said Prof Thompson has been a dedicated doctor and specialist for nearly 40 years and had never previously been investigated by a regulator.
He said he had a reputation as a 'hard-working and outstanding clinician and researcher, who has an international reputation as one of the leading paediatric liver specialists in the world'.
Mr Rich urged the tribunal members to impose an order of conditions involving supervision on Prof Thompson's registration, but the panel disagreed and said such a measure would be 'unnecessary and artificial', as they opted to take no further action.
Christopher Rose, for the GMC, said that Prof Thompson should be suspended to send a message to the wider public and the wider profession, given the seriousness of the failings found.
The tribunal had cleared Prof Thompson of the GMC's claims that he gave 'outdated, misleading' information on Martha's condition to a consultant colleague in the intensive care unit, and that he failed to mention her rash.
In ruling his fitness to practise was impaired, Mr Ince said: 'There had been a significant potential risk of harm to Martha and it was appropriate to send a message to the profession as to the importance of following the basic and fundamental principles as set out in good medical practice so as to ensure that the potential risks of an adverse outcome are always taken into account.'
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