Martha’s Rule: Empowering Patients, Families, and Carers, and Reinforcing Good Clinical Practice
On 20 February 2024, Amanda Pritchard, Chief Executive of NHS England, announced that a hundred NHS trusts in England, comprising larger hospitals with in-house critical care teams, will adopt Martha’s Rule from April 2024 onwards, prior to a planned national rollout to all acute hospitals. Patients admitted to hospital, and their families, will be enabled to seek an urgent second opinion from a different critical care team of doctors and nurses within that hospital, at any time of day or night, if a patient’s condition is rapidly deteriorating and they feel that appropriate care is not being provided.
Thirteen-year-old Martha Mills sustained a handlebar injury of her pancreas while falling off her bicycle, during a family cycling holiday in Wales in the summer of 2021. She was initially transferred by helicopter from a hospital in Aberystwyth to the University Hospital of Wales in Cardiff. Another helicopter journey then took her to a specialist tertiary unit for pancreatic injuries in children at King’s College Hospital in south London, where she was operated upon and later developed severe sepsis, only to succumb to refractory septic shock in the early hours of 31 August, a few days before her fourteenth birthday. Despite her parents’ concerns, Martha remained on the Rays of Sunshine ward and was not transferred to the nearby paediatric intensive care unit, where a bed was available, until it was too late. By then, she had already developed a skin rash, bled from an intravenous line in her arm and from a drainage tube from her abdomen, and had a fit in her mother’s arms. The Coroner for Inner North London, at an inquest into her death at St Pancras Coroner’s Court on 25 February 2022, declared that Martha’s death could have been avoided if only she had been transferred to the paediatric intensive care unit earlier.
The Chief Executive of King’s College Hospital, in a written response to Senior Coroner M.E. Hassell at St Pancras Coroner’s Court, dated 21 April 2022, stated that a programme intended “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” had “stalled…partly because of the pandemic.” Furthermore, “the escalation process needed to be refined and formalised through a standard operating protocol for children requiring critical care.” In plain speak, the working relationship between the two hospital departments needed to be improved upon, and the procedures for recognising clinical deterioration in children needed to be tightened up. Martha’s untimely death had also reinforced “the importance of parental concern as a trigger for early review.”
Martha’s Rule is the direct result of a concerted campaign by her media-savvy parents-Merope Mills, editor of the Guardian Saturday Magazine, and Paul Laity, a non-fiction books editor at The Guardian newspaper. Their efforts prompted the London-based cross-party think tank Demos to publish ‘Martha’s Rule: A New Policy to Amplify Patient Voice and Improve Safety in Hospitals’ in September 2023.
Martha’s Rule is a form of Patient Activated Rapid Response (PARR) service, whereby parents and family members can escalate patient care concerns to a different team within the same hospital. It was preceded by Condition H(elp), which was launched at the University of Pittsburgh Medical Center in 2005, in response to the death of Josie King in 2001 from septic shock secondary to an unrecognised central venous line infection, and allows concerned patients and relatives to directly call the in-hospital Rapid Response Team. Ryan’s Rule was introduced in Queensland Health public hospitals in 2013, following the death of two-year-old Ryan Saunders in 2007 from toxic shock syndrome, which complicated an undiagnosed Streptococcal infection. The three-step patient, family, carer escalation process is initiated by first raising concerns with a nurse or doctor. If not satisfied with the response, the nurse in charge of the shift is to be contacted. If still not reassured, 13 HEALTH can be phoned, and a Ryan’s Rule Clinical Review requested. Call 4 Concern is a more recent patient escalation system in the UK, which was launched at the Royal Berkshire NHS Trust in Reading in 2009 and enables patients and relatives to directly contact the hospital’s Critical Care Outreach Team.
Unfortunately, a number of issues related to hospital care in England-by no means unique to this nation- have persisted to the day and continue to threaten patient safety, despite all efforts to identify and then tackle them thus far. In addition to an NHS culture that defers to hierarchy and fosters paternalistic attitudes at senior levels, patient care is further compromised by staff shortages, the breakdown of traditional team structures, inadequate supervision and support for junior medical staff, poor working relations between hospital departments, various cognitive biases shared by doctors and nurses, and a reluctance to both admit to and learn from mistakes. Despite various “early warning scores” alerting doctors and nurses to deterioration in a patient’s condition, warnings that seem obvious in retrospect continue to be dismissed and thus not acted upon. It might seem obvious that if a patient’s condition is not improving as might be expected despite appropriate treatment, either the diagnosis of the condition is wrong, or, if it does happen to be the correct one, either the prescribed treatment is ineffective or a complication has developed. Either way, periodically reviewing diagnoses and treatment plans, and anticipating likely complications are all part of good clinical practice- essential to avoid catastrophes such as that which tragically befell Martha Mills and prematurely cut short a life full of promise. Martha’s Rule will have achieved its purpose if it empowers patients, their families, and their carers to challenge treatment when concerned and to seek an informed and unbiased second opinion, all in the quest for high-quality in-hospital care.
Ashis Banerjee