Martha's Rule

Martha Mills (2007-2021)

Martha's Rule is a patient safety initiative to be implemented in NHS English hospitals from April 2024. It gives patients, families, carers and staff in hospitals who have concerns about a deteriorating patient's treatment round-the-clock access to a rapid review from a separate care team. NHS chief executive Amanda Pritchard said the programme would undoubtedly 'save lives in the future'. 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. Victoria Atkins, the Secretary of State for Health, said that the 'introduction of Martha’s Rule from April will put families at the heart of the patient’s own care, recognising the critical role they have in the treatment of loved ones'. The patient safety specialist James Titcombe OBE stated: 'Change in the NHS can feel painfully slow, but every so often a moment comes along when something truly transformational happens . . . Martha’s Rule is destined to forever change the NHS for the better.'

Background

The origins of Martha's Rule lie in the patient safety activism of Merope Mills, whose daughter, Martha Mills, died in hospital a few days before her 14th birthday, on 31 August 2021. Merope Mills is a journalist, currently the editor of The Guardian Saturday magazine and a Guardian executive editor. In September 2022, on what would have been Martha's 15th birthday, Mills wrote about Martha and her treatment at King's College Hospital (KCH), in south London, 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 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 Secretary of State for Health Wes Streeting having said that he was moved to tears by the BBC interview. Within two weeks, 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.

Henrietta Hughes, 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 Mills'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, KCH; King's is a specialist referral centre for the treatment of pancreatic trauma, and she was treated by the hospital's paediatric liver team. Rays of Sunshine is well-funded from private overseas liver transplant patients. KCH's own Serious Incident Investigation Report – on which Mills drew in writing her Guardian piece – noted that Martha was kept on the ward as she deteriorated, even 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 KCH's liver team had transferred her to PICU. King's College Hospital has admitted breach of duty of care. The hospital trust apologised for the mistakes made, and said in a statement that it 'remains deeply sorry that we failed Martha when she needed us most'.

In her Guardian article, Mills wrote that although she had, along with Martha's father, 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, one symptom of which was that she bled copiously from the tubes in her arms and stomach. But her parents were never told she had sepsis, and other symptoms were kept from them and left untreated. Mills had expressly voiced her fear that Martha would die of septic shock over the Bank Holiday weekend, when the consultants weren't around. There was no single consultant with overall responsibility for Martha's care. On the day of Martha's severe deterioration, on the August Bank Holiday Sunday, the teenager 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 registrar but the doctor ignored her and pursued a misdiagnosis. There were no consultants to turn to on the ward, because it was a weekend.

Athough Martha met all of the hospital's criteria for escalation, she remained on the ward: it wasn't a case of a missed sepsis diagnosis – as sepsis was recognised – but of failure to escalate. 'Unbelievably,' Merope Mills has said, 'the duty consultant, at home, who had failed to draw up a plan for her care that day, said "categorically" that a potentially life-saving bedside visit from a member of ICU shouldn’t happen because it would increase my anxiety. No doctor visited Martha overnight and after she began to go into septic shock, no recovery was possible.' KCH's Serious Incident Investigation Report noted that there were poor relations between the 'high-status' liver team working on Rays of Sunshine and paediatric intensive care: the liver team had a reputation for being dismissive of their colleagues in PICU. In the Guardian, Mills wrote that the liver team doctors on Rays of Sunshine were overconfident, complacent and failed to listen to her in part, she believed, because she was a woman who they had dismissed as anxious. 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. Mills wrote in the British Medical Journal that the doctors' failure to listen to her 'was not only cavalier, it was fatal.'

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 designed to learn from Martha's death. 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 similar patient safety process in Queensland, Australia, which provided the inspiration for the name Martha's Rule. Martha's Rule also draws on Call 4 Concern, an initiative introduced in a number of British hospitals. Evidence shows that such initiatives are not overused or abused by patients or families, and can result in necessary escalations which would otherwise not have occurred.

Mills has argued that Martha's Rule will not only save lives but bring about a significant shift in the culture within hospitals towards patient power. Mills said of her experience at Martha's bedside: 'I was "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.

Implementation

In September 2023, the then 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 to the Secretary of State on 20 October 2023. The following month, Merope Mills spoke at the NHS England chief nurses's summit. Mills wrote of Martha's Rule in the British Medical Journal: 'I realise its introduction has come at a time of crisis in the NHS. But as many supportive doctors have told me, such an escalation system ... protects patients and overstretched healthcare professionals alike. Doctors and nurses are under great pressure, but this is exactly when Martha’s Rule is needed most.' On 21 February 2024, NHS England and the Department of Health announced that the roll-out of Martha's Rule would begin with 100 hospitals – acute provider sites which already have round-the-clock critical care outreach capability – from April 2024 to March 2025. During the same period, work would be done on proposals to extend Martha's Rule to all hospitals.