Martha's Rule

Martha Mills (2007-2021)

Martha's Rule is a patient safety initiative to be implemented across NHS England. It ensures that all hospital staff have access to a 24/7 escalation route for rapid review of acute patients on wards and that this route must also be available to patients, their families, carers and representatives. According to Henrietta Hughes, the Patient Safety Commissioner for England, it is a measure that will save lives and is also a 'cultural intervention', which will help to flatten hierarchies within medicine, improve listening on the part of clinicians and give patients and their families greater agency. The Secretary of State for Health, alongside NHS England, has announced that the implementation will begin in April 2024.

BACKGROUND

The origins of Martha's Rule lie in the patient safety activism of Merope Mills, whose daughter, Martha, died in hospital a few days before her 14th birthday, on 31 August 2021. Mills is a journalist, currently the editor of The Guardian Saturday magazine. In September 2022, on what would have been Martha's 15th birthday, Mills wrote about Martha and her treatment at King's College Hospital in an article for the Guardian, which was widely read all over the world and has become a text studied in medical schools. A year later, in September 2023, Mills gave an interview on the BBC Radio 4 Today programme, telling the story of Martha's treatment and making the case for Martha's Rule. Within a day of Merope of the broadcast, Martha’s Rule was discussed in the House of Commons. Within a fortnight, the Conservative government had backed the initiative and the Labour Party in opposition had also expressed support, the shadow health secretary Wes Streeting having said he was moved to tears by the BBC interview. Within a week or two, the Times, Daily Telegraph, Guardian and Daily Mail ('A second opinion', 7 September 2023) had followed suit with leading articles expressing their backing of the campaign. The British Medical Journal ran several pieces on Martha's Rule and the editor-in-chief wrote in support of the initiative.

The Patient Safety Commissioner has written that the 'tragic death of Martha is a clear example of epistemic injustice where the views and voices of patients are not heard and acted on. The information and insights from Martha’s parents were not believed, were undervalued, or were not understood – but it is not an isolated case.' Martha's was a preventable death from septic shock, following a series of hospital mistakes. She had a treatable pancreatic injury following a holiday bike accident. Martha had a bed for several weeks on Rays of Sunshine Ward, King's College Hospital (KCH), in south London, one of three specialist centres in England for the treatment of pancreatic trauma. Martha was kept on the ward as she deteriorated, though there were five occasions when it would have been appropriate to involve paediatric intensive care (PICU). Had she been moved to PICU, where a bed was available, observation and treatment would have different.. In 2022 a coroner ruled that Martha would most likely have survived if medics had identified the warning signs and transferred her to PICU. King's College Hospital has apologised for mistakes and said in a statement that it 'remains deeply sorry that we failed Martha when she needed us most'.

Implementation

o In September 2022, on what would have been Martha's 15th birthday, Mills wrote about Martha and her treatment at King's College Hospital in an article for the Guardian, which was widely read all over the world and has become a text studied in medical schools. Mills wrote that although she had, along with Martha's Dad, Paul Laity, raised concerns about Martha's deterioration, her opinions were ignored or dismissed by the consultants and junior doctors on Rays of Sunshine Ward at KCH. The article recounted that Martha developed severe sepsis six days before she died, but her parents were never told this; other symptoms were kept from them and left untreated. On the day of her severe deterioration, Martha had ongoing sepsis from an unknown source, very low blood pressure, a fever and a rapid heart rate. She then developed a rash, which Mills, by her daughter's bedside, was worried was a sepsis rash: she relayed this concern to the doctor but, though she was correct, the doctor ignored her and pursued a misdiagnosis. There were no consultants to turn to, because it was a weekend. Martha wasn't moved to intensive care, despite meeting all the hospital criteria for escalation: KCH's own Serious Incident Investigation Report – which Mills drew on in writing her piece – noted that there were poor relations between the high-status 'liver team' working on Rays of Sunshine ward and paediatric intensive care: the liver team had a reputation for being dismissive of their colleagues in PICU. Against hospital protocol, Mills has noted, the duty consultant resisted a review of Martha because it would have increased Mills's anxiety. In the Guardian, Mills wrote that the liver team doctors on Rays of Sunshine Ward were overconfident, complacent and failed to listen to her in part because she was a woman. Although nurses had noted Martha to be at risk days before she died, such was the hierarchy on the ward that their opinion went unregarded by the doctors.

Following the significant public response to the Guardian article, Mills and Laity were asked by the think-tank Demos to work jointly on a patient safety initiative. After research and a meeting with NHS representatives and other health stakeholders, the decision was taken to concentrate on Martha's Rule. Mills had been approached by health workers in Australia, who told her about Ryan's Rule, a patient safety process in Queensland, Australia. Martha's Rule also draws on Call 4 Concern, an initiative introduced in a number of British hospitals.

which Mills argued would not only save lives but bring about a significant shift in the culture within hospitals towards patient power. Mills, who had been at Martha's bedside as she fatally deteriorated, said: 'I had been "managed", I hadn’t been listened to and I felt powerless ... If a patient and family escalation system such as Martha’s rule had existed – and had been clearly advertised around the hospital with posters and stickers – I’m sure I would have used it and it could well have saved Martha’s life.' Mills called for an increase in patient and family agency in a hospital environment – something long supported in principle by the NHS but not sufficiently achieved in practice.

The Secretary of State for Health and Social Care, Steve Barclay, asked Henrietta Hughes, the Patient Safety Commissioner to work on an implementation plan for Martha's Rule. After four 'sprint' meetings involving NHS Trusts, the Health Ombudsman, the CQC, the GMC, the Patients' Association and other bodies, Hughes submitted her recommendations on 20 October 2023. Merope Mills has spoken at the Patient Safety Movement summit and NHS England chief nurses's summit. An official announcement regarding the roll-out of Martha's Rule is to be made in February 2024: implementation across NHS England is to begin in April 2024.