NHS England (2024a) has recently provided details on how Martha's Rule will be implemented in the NHS. The first phase will start in April 2024. There will be a phased introduction, beginning with at least, the report states,100 adult and paediatric acute provider sites. These will already offer a 24/7 critical outreach capability. NHS England will shortly be asking for expressions of interests from Trusts. A document will be created that will outline the additional support available from NHS England, including funding for project resources and access to specialist support and expertise. The initial roll-out experience will inform future plans and policy across the NHS for Martha's Rule in 2025-2026 and across other clinical settings such as community and mental health hospitals. The roll out is to be welcomed and Martha's Rule will provide a useful tool to enhance patient safety in the NHS and will contribute to the development of an NHS patient safety culture.
Why Martha's Rule is needed
The call for Martha's Rule arose out of the tragic death of 13-year-old Martha Mills, who died from sepsis in 2021 at King's College Hospital, London. There was a failure to recognise that she required intensive care treatment. At the inquest, senior coroner Mary Hassell said:
‘She was not transferred to intensive care as she should have been … All the evidence I have heard boils down to that. I find the likelihood is if she'd been transferred to intensive care, she would have survived.’
Martha's mother, Merope Mills, has campaigned for a system that can escalate concerns from the patient and family, similar to Call 4 Concern (University Hospitals Dorset, 2024) and other systems. Demos, a cross-party policy think tank, supported her campaign, and produced a report (Curtis and Wood, 2023). The report clearly explains the need for Martha's Rule and the foreword by Merope is an extremely powerful and heart-rending one, cataloguing the tragic events that led to the death of her daughter. (Mills, 2023). It was inevitable that after the publication of this report (Curtis and Wood, 2023), Martha's Rule would be implemented in the NHS. The reasons for supporting it were so clearly and forcibly expressed by Merope and others.
The tragic circumstances that led to the implementation of the rule will never be forgotten. Those implementing Martha's Rule will, however, need to traverse a rocky road in the NHS for it to work effectively and this should not be underestimated. History has not served the NHS well when it comes to patient safety policy development and practice.
Unforgivable, avoidable treatment errors continue to be made on an all-too-frequent basis in the NHS. NHS Never Event data (NHS England, 2024b) is testament to this, along with past reports into patient safety crises such as at Mid Staffordshire (Francis, 2013), Shrewsbury and Telford (Ockenden, 2022) and East Kent (Kirkup, 2022).
Challenges facing Martha's Rule
Although successive governments have developed many well-crafted patient safety policies and initiatives, some of these have floundered. Practical patient safety lessons from past crises have gone unlearnt in many instances. Also, as a result of dealing with these patient safety crises, a complex, fragmented and overlapping system of NHS healthcare regulation and governance has developed within which patient safety policies and practices must operate.
Several NHS patient safety stakeholders have stated this, including the Care Quality Commission (CQC):
‘Arm's-length bodies, including CQC, royal colleges and professional regulators, have a substantial role to play within patient safety, but the current system is confused and complex, with no clear understanding of how it is organised and who is responsible for what. This makes it difficult for trusts to prioritise what needs to be done and when.’
CQC, 2018: 6
The Professional Standards Authority (PSA) stated:
‘Structural flaws in the safety framework: the patient and service user safety landscape is fragmented and complex. Concerns raised often fall between organisations or are left unaddressed due to jurisdiction issues or insufficient powers.’
PSA, 2022: 10
Martha's Rule is an addition to the current arsenal of patient safety tools and policies. Martha's Rule will also have to co-exist with other patient safety policies and tools such as statutory and professional duties of candour. The statutory duty of candour is now subject to government review (Department of Health and Social Care (DHSC), 2023) and there have been criticisms about its effectiveness, including from Action against Medical Accidents (AvMA):
‘AvMA finds that Trusts do not provide enough information to patients regarding the Duty of Candour even alongside their complaint procedures.’
AvMA, 2024
This co-existence, sharing of information and the pooling of scarce financial and other resources will need to be successfully managed so that patients are fully aware of Martha's Rule and what it can offer. Martha's Rule should not be lost in a confusing, complex and fragmented patient safety, health regulation and governance landscape with its many competing initiatives.
Communication failures
Past NHS complaints and litigation cases often involved communication failures. If some nurses and doctors had communicated better with their patients, some of these complaints and litigation cases might never have been made. Communication failures can be seen as a fundamental factor that led to Martha's death. In her foreword to the Curtis and Wood report, Merope explains how she was managed and condescended to by clinicians:
‘I wasn't listened to, and that made the ward less safe. My challenge wasn't welcomed, and I was ignored; it turned out, tragically for Martha, that I was correct.’
Mills, 2023: 6
Professional silos and clinical hierarchies
Merope describes poor interdepartmental relations and professional hierarchies and silos:
‘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 intensive care. There was no formal “outreach” between the two departments.’
Mills, 2023: 5
We can also see professional silos and clinical hierarchies being discussed in relation to Never Events in surgery, and how these may contribute to errors being made. Interview evidence in the report by the Healthcare Safety Investigation Branch (HSIB) (2021) stated that it was accepted practice among teams for a surgeon to leave theatre before the end of a procedure and was therefore not present for the patient safety sign out procedure.
Surmounting teamworking failures
Kirkup (2022) chronicled acute teamworking failures in NHS maternity care in his report, which can also be seen as in issue in several other patient safety crisis reports. Kirkup (2022) states the nature of some of these teamworking challenges:
‘Poor teamworking was raised as a prominent feature by many of those we interviewed. Some obstetricians had “challenging personalities … big egos … huge egos”. Midwives showed “cliquey behaviour” and there was an in-group, “the A-team”. This behaviour was displayed “in front of women”. One clinician told us that “many times we could have done better … the culture in obstetrics and the relationship with midwifery were poor”.’
Kirkup, 2022: 4
A lack of empathy, professionalism and compassion and a failure to listen are also key patient safety pinch point areas for those implementing Martha's Rule to navigate and overcome. It would be naïve to think otherwise, given the evidence of these failures in past patient safety investigations.
Other issues with implementing Martha's Rule
Those introducing Martha's Rule will also need to navigate several other matters. How, for example, will patients know when to ask for a second opinion under Martha's Rule? We have seen AvMA concerns about inadequate trust publicity about the statutory duty of candour (AvMA, 2024).
There is also the danger of patients' relatives being ‘red flagged’ by the healthcare team treating them if they ask for a second opinion. The team may be defensive or dismissive. Patients who ask for a second opinion may become labelled as ‘difficult’ during handovers.
Another concern is what happens if the clinicians treating the patient disagree with the independent opinion? Who will decide? Who has responsibility for final outcomes?
What if the second opinion later turns out to be wrong or negligent? There are then legal liability issues raised. These are just some early thoughts that have been shared with me by colleagues when discussing Martha's Rule.
Conclusion
Martha's Rule is to be welcomed. It has the potential to enhance patient rights and safety in the NHS. It will also assist efforts to develop a proper and effective patient safety culture. The path for Martha's Rule implementation will, however, not be an easy one to navigate given the challenges it must meet and overcome. There is a need for Martha's Rule policy developers and implementers to be aware of these challenges and to factor them into work being done. However, NHS culture change will not happen overnight, and implementation will take some time and should not be rushed. There should be no knee-jerk implementation of Martha's Rule.