Martha’s Rule and NHS Patient Safety

Martha’s Rule is currently a topic of intense discussion and debate. Behind the rule is a sad and tragic story which strikes at the heart of NHS care delivery – clinical failures and the death of a 13-year-old girl. Reporting the Coroner’s Inquest proceedings, The Guardian Newspaper stated that “Martha Mills would probably not have died of sepsis if King’s College hospital doctors had heeded warnings” and moved her to intensive care.

Martha’s mother, Merope, recounted her experiences and the events that unfolded in a foreword to a recently published report by policy think tank Demos. She talks in detail about what happened, her regrets and what should be done to stop the same tragic chain of events happening to other people. Silo thinking, poor interdepartmental relations, and team reputations are among the important issues Merope raises. She recalls being ‘talked to, rather than listened to’, how she felt, ‘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’.

The patient is always the weaker party in the care equation

Merope’s powerful testimony illustrates the dynamics of the power relationship that exists between health carers and patients. Doctors, nurses, and other health carers are always going to be in a more powerful position compared to those whom they treat. They have the specialist knowledge and skill that the patient so urgently needs, therefore the patient is always going to be the weaker party. They are ill, in a strange environment, most probably a hospital gown and fearful of what is going to happen next. Conversely the doctor and/or nurse is in their familiar environment.

There are codes of professional practice - the GMC, NMC, CQC - alongside other regulatory bodies and of course the law itself, which collectively attempt to redress this power imbalance. The creation of rules, regulations, laws, and codes are one thing; however, the key issue is how all these work together in practice to safeguard patients at ward and other levels. We need to ask ourselves whether patients are adequately protected when it comes to challenging a care decision and seeking more help. I would argue, as Merope does, that they are not. Much more needs to be done to give patients, their relatives, and carers, a firm platform from which to seek more help and to appropriately challenge what is going on if that need arises.

The NHS needs to do more to develop a patient safety culture

I accept that some degree of error in health care delivery is always going to be inevitable. Nobody is infallible. Health care can be complex and is dependent on human decision making and interaction. What we can do, however, is try and successfully manage risk by developing a proper patient safety culture.

History has not served the NHS well when it comes to patient safety culture development

Unfortunately, the NHS has poor form when it comes to implementing the improvement recommendations made from past patient safety investigations. Patient safety crisis events continue to occur at an alarming rate with often the same or similar errors being repeated. Mid Staffordshire, Shrewsbury and Telford, East Kent are to name but a few of such cases.

In the year 2000 the Department of Health published An Organisation with a Memory, a report highlighting major patient safety issues, In 2023 many of those issues are still with us. Hospitals are at various levels of patient safety maturity across the NHS.

The implementation gap

The NHS has a long history of trying to grapple with patient safety issues and not all is doom and gloom. There have been successes as well as failures. However, the failures do tend to eclipse the successes. We do have a good knowledge of patient safety issues but there is a glaring, ‘implementation gap’. The charity, Patient Safety Learning has pointed this out, saying:

“We consider that a key reason for the persistence of avoidable harm is an ‘implementation gap’ in patient safety in the UK, the difference between what we know improves patient safety and what is done in practice”. These words were echoed recently by the Parliamentary and Health Service Ombudsman.

The way forward

The way forward is to adopt the proposals by Demos and Merope Mills. There are good models of doing what is recommended overseas (such as Ryan’s Rule) and in the UK (Call 4 Concern), however, it is clear that there is not yet a sufficiently developed, mature NHS-wide patient safety culture to stop another tragic situation like that of Martha Mills from happening again. We urgently need Martha’s Rule formally implemented in the NHS. Martha’s rule does appear to have a groundswell of support from various places and early signs are promising that such a rule could well be implemented.