The introduction of Martha's Rule in the UK healthcare system marks a significant stride towards enhancing patient safety and empowering patients and their families. This move comes at a time when public satisfaction with the NHS has plummeted to a record low of 29%1. While Martha's Rule will be formally implemented within NHS acute hospitals, some independent healthcare providers are already looking at how this new rule affects them.
Background
Martha Mills was a 13-year-old girl who tragically died from sepsis in 2021 after being admitted to hospital with a pancreatic injury sustained from a bicycle accident. Despite her parents' repeated concerns about her deteriorating condition and symptoms of sepsis, Martha was not escalated to intensive care in time, leading to her preventable death.
Martha Mills: Prevention of future deaths report
The coroner's inquest and serious incident investigation into the death of Martha Mills, along with her parent's testimony, identified several key findings that contributed to her death2. Sadly, these are not factors that are isolated to Martha's case. Over the years, similar issues have been identified at other inquests and in medical malpractice claims in the NHS and independent sectors3 4.
- Failure to escalate care
Despite multiple opportunities and clear signs of deterioration, Martha was not escalated to intensive care promptly. The inquest concluded that if she had been transferred earlier, she would likely have survived2.
- Inadequate Communication and Documentation
Due to poor inter-departmental relationships between specialist hepatology teams and paediatric intensive care departments, there was a significant communication failure(footnote 2). The lack of electronic records recording paediatric observations meant monitoring Martha's symptoms was sub-optimal2.
- Misdiagnosis and Ignored Warnings
Martha's symptoms, including high fever, low blood pressure and rash, were misdiagnosed as a simple infection. Her parents articulated their concerns regarding sepsis but were repeatedly dismissed by medical staff3 5.
- Cultural and Hierarchical Issues
The hospital's culture did not encourage or facilitate nurses challenging senior doctors or escalating deteriorating patients. This hierarchical structure and paternalistic approach to medicine contributed to the failure to escalate Martha's care5 6.
- Absence of Senior Medical Staff
During critical periods, no senior consultants were present to review Martha's condition. This absence was particularly noted over weekends and bank holidays5 6.
The coroner's report and subsequent investigations concluded that Martha's death was preventable. The failure to transfer her to intensive care and the mismanagement of her condition were critical factors. Like many others, the inquest highlighted systemic issues within the healthcare organisation, including poor teamwork, inadequate patient safety protocols and a lack of proactive critical care outreach. All roads lead back to communication skills.
Martha's Rule
This case has led to the introduction of "Martha's Rule" in the NHS in England. It is a patient safety initiative, and the 143 hospital sites that will test and roll out Martha's Rule in its first year have now been announced. It aims to provide patients and their families the right to request a second medical opinion if their concerns are not addressed. The rule allows for an independent clinical review, which must be conducted by professionals not involved in the patient's current care, ensuring unbiased assessments and recommendations.
Martha's Rule consists of three main components:
24/7 access to rapid review for staff:
All staff must have access to round-the-clock access to a rapid review from a critical care outreach team. This team can be contacted if there are concerns about a patient's condition.
24/7 access for patients and families:
Patients, families, carers, or advocates should have access to the same critical care outreach team, allowing them to request an urgent review if they are worried about a patient's condition deteriorating.
Structured information gathering:
A structured approach to obtaining information about a patient's condition directly from patients and their families at least daily should be implemented.
Independent healthcare providers
The demand for private healthcare has grown significantly for numerous reasons. These include not being seen quickly enough by the NHS, the ease with which patients can book private healthcare appointments, and the rise in the number of people who have private health insurance. Such demand is for a variety of healthcare needs: seeing a GP or a doctor for an initial consultation, diagnostic scans, an operation or ongoing treatment for cancer and other conditions. Additionally, independent healthcare providers are delivering more NHS services, with the sector undertaking over 10% of all NHS elective activity in 20237. Due to prolonged NHS waiting lists, the healthcare system, across the board, is seeing more complex patients demonstrating a time-related deterioration in their condition. This can impact the duration of an operation and subsequent post-operative recovery, potentially leading to an increased risk of deterioration. Government figures suggest that approximately 6,000 patients are transferred from private hospitals to the NHS yearly due to complications8.
Although the focus is on the new rule being implemented in the NHS, many of the factors which the Coroner found contributed to Martha's death are not isolated to the public sector. Communication skills, documentation, and failure to escalate can also be common themes in many claims against independent healthcare providers. Implementing an equivalent to Martha's Rule could, therefore, assist with enhancing patient safety within the independent sector. Of course, any equivalent initiative must be relevant to the services provided. Private hospitals, those providing out-of-hours services, and those providing insourcing and outsourcing services are some of those who are likely to have the patient demographic for both patients and providers to benefit the most from any such initiative.
By adopting an equivalent to Martha's Rule, independent healthcare providers can align themselves with leading safety practices in the healthcare industry, demonstrating a proactive approach to improving patient safety and adhering to regulatory standards. Moreover, in some instances, it could lead to quicker identification and management of deterioration, potentially preventing adverse outcomes.
Conclusion
Martha's Rule empowers patients and their family members to actively participate in their care and treatment and reinforces the fundamental principles of listening to people who use healthcare services and their families and acting on what they say. This reflects the law around consent which is clear that there is no place for paternalism in healthcare. By allowing patients and families the right and authority to request an urgent review, Martha's Rule gives providers the chance to enhance trust, patient safety and patient satisfaction through person-centred practice.
Martha's Rule empowers patients and their family members to actively participate in their care and treatment...
The principles underlying the foundations of Martha's Rule, such as effective communication, collaborative teamwork and the appropriate escalation of patients, are not exclusive to the NHS. Private healthcare providers – particularly those providing acute services - are encouraged to implement an equivalent patient safety initiative to improve their clinical risk profile. At WTW, we recognise that it is everyone's responsibility to improve patient safety.
Footnotes
1 Public Satisfaction with the NHS: results from the British Social Attitudes Survey: (2023) Return to article undo
2 Martha Mills: Prevention of future deaths report. (2022) Inner North London Coroners Court. Return to article undo
3 Response from Kings College Hospital. 2022. Return to article undo
4 Tingle J, Cattini A. Martha's Rule and NHS patient safety. British Journal of Nursing. 2023 Oct 12;32(18):908-9. Return to article undo
5 Merope Mills. 'We had such trust; we feel such fools: how shocking hospital mistakes led to our daughter's death Return to article undo
6 Curtis P. Wood C. Martha's rule: a new policy to amplify patient voice and improve safety in hospitals. Demos. Sep. 2023.u Return to article undo
7 Independent Healthcare Provider Network (IHPN) Quarterly Data – NHS Activity, April 2024 Return to article undo
8 Centre for Health and Public Interest (CHPI): CHPI Impact Report 2023 Return to article
Co-authored by Anna Walsh, Partner at CMS
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