The critical issue of a patient's right to a second medical, clinical review has recently hit the headlines with Martha's Rule. The rule relates to the death of a 13-year-old girl in NHS care in tragic circumstances. The Guardian reported: ‘Inquest says Martha Mills would probably not have died of sepsis if King's College Hospital doctors had heeded warnings’ (Siddique, 2022).
Merope Mills, Martha's mother, writes in detail about what happened and what should happen next, in a foreword to a report by policy think-tank Demos (Curtis and Wood, 2023). She also spoke to the national media, with her words causing shockwaves throughout the nation and the NHS. There are acute patient safety lessons to learn from this tragedy.
She (Curtis and Wood, 2023) writes about the importance of patients, carers and families having a formalised right to an urgent clinical review and second opinion, where there is a suspected deterioration of the patient's condition or where they have serious concerns. Her discussion strikes right at the heart of the patient safety problems that have persistently plagued the NHS and continue to do so. It is a wake-up call to all those working in the NHS. She identifies several acute systemic NHS patient safety failings, which include those outlined below.
Professional silos
One issue she discusses are the professional silos and hierarchies, for example:
‘It's been explained to us that the liver team is “very hierarchical” (Nurses identified Martha as ‘at risk’ seven days before she died, but their opinions weren't absorbed.) We found out later that a crucial reason why the consultants didn't consider referring my daughter is that for years they had been dismissive of their junior colleagues in paediatric care.’
Merope goes on to state that there was no formal ‘outreach’ between the two departments, using phrases such as ‘silo thinking’, ‘poor interdepartmental relations’ and ‘a team with a particular reputation’ in her discussion.
Professional hierarchies have been cited as a major patient safety issue before and several recent crises reports into maternity care point to the existence of professional chasms, and extremely poor relationships between obstetricians, paediatricians and midwives. A quote from the Morecambe Bay report highlights this point:
‘Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives …’
This issue of professional silos, hierarchies and poor working relationships needs to be sorted out urgently. Amid professional turf wars, the patient, who should be at the centre of all the NHS does, seems to be forgotten.
Merope states that, given the factors described above, patient-centered measures are needed to lessen their effect, and this requires the formalisation of Martha's Rule in the NHS.
Poor communication
Good communication between health carers is essential for good care, treatment and for building trust. Unfortunately, communication failures can be seen in countless patient safety investigation reports, as starkly illustrated by the East Kent Maternity Report (Kirkup, 2022:4), where unforgivable patient communication errors are noted:
‘In other cases, women themselves were blamed for their own misfortune. A woman admitted to hospital to stabilise her type 1 diabetes pointed out to antenatal ward staff that they were not adjusting her insulin correctly. She was told that “we're midwives not nurses and we don't deal with diabetes … it's not our issue and you don't fit in our box”.’
That is unforgivable conduct. In the foreword to the Demos report (Curtis and Wood, 2023), Merope recalls being ‘talked to, rather than listened to’, ‘managed and condescended to’ and, perhaps most devastatingly, how she desperately wishes she had ‘felt able, with no fear of being the target of ill-temper or condescension, to ask for a second opinion from outside the liver team when I became concerned about Martha's deterioration’.
Patients are at a disadvantage
Merope's powerful testimony and, over the years, several reports such as Kirkup's (2015; 2022) critique the dynamics of the power relationship that exists between health carers and patients. Failures here can and do have catastrophic, deadly consequences. It must be recognised that there will always be an imbalance in the power relationship between health carers and patients. This justifies the formalisation of Martha's Rule in the NHS. Sadly, some patient safety crises reports that I have read over the years show that some nurses, doctors and other carers do not put the patient first, treating them as an afterthought.
Are codes of practice effective?
An argument could be made that professional codes of conduct that nurses, doctors and other health professionals have to follow are sufficient to safeguard patient rights. For example, the General Medical Council (GMC) practice code states that, in providing clinical care, the doctor must:
‘(d) consult colleagues where appropriate (e) respect the patient's right to seek a second opinion.’
The GMC's updated practice code, which comes into force on 30 January 2024, under ‘Treating patients fairly and respecting their rights’, point 18, states:
‘You must recognise a patient's right to choose whether to accept your advice, and respect their right to seek a second opinion.’
GMC, 2024:11
Codes are not enough
Although the GMC has given some formality to a second opinion, this in itself is not sufficient. Such a right should be formalised and more widely publicised, so that patients and others know it exists – and that it is a right. Being tucked away in a professional code that patients will most likely never read is not good enough.
A logical place for Martha's Rule could be within The NHS Constitution (Department for Health and Social Care, 2023). However, locating it in this document without any supporting publicity, would be inadequate. It is doubtful The NHS Constitution is widely read by patients.
Past and current patient safety crises investigation reports such as Kirkup (2015; 2022), include stark examples of a lack of health carer compassion, patients not being listened to and gross failures in communication. Although the Nursing and Midwifery Council and the GMC have clearly thought-out, articulated codes. These are not in themselves adequate to safeguard patients' interests. Much more is needed.
Patient safety maturity in the NHS
Merope (Curtis and Wood, 2023) cited key patient safety failings, which have been acknowledged in the NHS for several years – and have been cited in various reports (Francis, 2013), Ockenden (2022) and Kirkup (2022). The NHS has bad form when it comes to learning lessons from past patient safety crises and implementing change. History patently has not served the organisation well when it comes to patient safety culture. Some hospitals are more patient safety mature than others; however, in 2023, many issues identified in An Organisation with a Memory (DH, 2000) are still with us.
Implementation gaps
A key patient safety concern that permeates throughout the NHS is what can be termed ‘an implementation gap’ (Patient Safety Learning, 2022) – the difference between what we know and what we do, the chasm between theory and practice. This gap makes the need to formalise Martha's Rule ever more urgent.
Next steps
There is undoubtedly going to be concerns in hospitals that Martha's Rule will result in resourcing difficulties. If patients use Martha's Rule frequently, this that will eat up valuable clinical resources. However, such a fear will probably be unfounded.
‘In 2019, a further evaluation of C4C [Call 4 Concern] referrals in Royal Berkshire was carried out. Over a seven-year period, 534 calls to C4C were made. The study found the service was being appropriately activated, with only 5% of referrals deemed not to be a C4C.’
A number of models that could be adopted to underpin Martha's Rule are discussed in Curtis and Wood (2023), including Ryan's Rule (Queensland Government, 2023) and in Call 4 Concern (University Hospitals Dorset, 2023).
Support for Martha's Rule
There appears to be a groundswell of support for Martha's Rule. Davies (2023) reported that Health and Social Care Secretary Steve Barclay is committed to introducing Martha's Rule in England with plans to do so in development.
Other issues for implementation
It is important not to rush the implementation of Martha's Rule into the NHS. We need clearly thought-out proposals that will apply to all trusts. We do not want watered down versions applying to some and not to others. Although there are varying levels of patient safety maturity in the NHS hospitals and resources, Martha's Rule should be non-negotiable.
It is important that Martha's Rule is not simply hidden away, within documents that the average patient will most probably never read. Publicity, implementation and support will be key. There will also be challenges for nurse, medical and other healthcare educators. The implemented scheme needs to be discussed fully with staff and learners, along with the reasons behind its introduction.
Other issues that will need to be addressed include what concerns are recognised as triggering the second opinion review process and what happens if there are disagreements between the reviewing team and the treating clinicians.
Conclusion
The NHS in England needs and will have Martha's Rule. This will work to rebalance the power distribution and dynamics between nurses, doctors and patients. Such a rule is urgently needed in the context of previous patient safety crises investigation reports, supported by the testimony of Merope and her family, following the tragic death of Martha. Merope has shone a powerful light onto NHS patient safety and has identified serious failings.
NHS hospitals are at different levels and stages of patient safety maturity, and there are presently not enough safeguards to stop what happened to Martha and her family happening again to others. We do, however, need to guard against implementing Martha's Rule too quickly, to avoid a kneejerk-type policy implementation. In the past, such reactions have sadly characterised much patient safety policy implementation.