Patient safety
Martha’s Rule: implementation and key priorities
The Westminster Health Forum recently brought together stakeholders, clinical leaders and policymakers to discuss the implementation of Martha’s Rule, which aims to provide patients, families, carers and staff with 24/7 access to a rapid review, from a separate critical care team, when concerns arise about a patient’s deteriorating condition. Louise Frampton reports.
At the Westminster Health Forum’s conference on patient safety, experts gathered to discuss the key priorities for the implementation of Martha’s Rule – a national patient safety initiative named after Martha Mills, who died of sepsis, after her parents’ concerns were ignored by medical staff. Dr. Ron Daniels, a Founder and Chief Executive of the UK Sepsis Trust and a Vice President of the Global Sepsis Alliance, highlighted the importance of changing the culture in healthcare, to prevent similar tragedies from happening in the future. “It’s three years now since Martha Mills
tragically died in 2021, at the age of just 13. The inquest following her death ruled that her death was almost certainly avoidable. Following that episode, her parents – Merope and Paul – started on a crusade, which has resulted in a ministerial mandate to implement Martha’s Rule,” he explained. “We see 150 avoidable deaths per week across
the NHS. However, as we’ve emerged from the COVID pandemic, it’s very likely that horrific number of 150 avoidable deaths per week, might have increased quite significantly,” he commented. Despite these concerning figures, Dr. Daniels
pointed out that there are “lots of things that can be directly implemented and used to save lives.” He introduced Polly Curtis, the Chief Executive
of the cross party Think Tank, Demos, who went on to provide an insight into the events that led up to the introduction of the rule, and the development of the policy. “I’m now sitting on the group that is
overseeing the implementation of Martha’s Rule, which is chaired by Henrietta Hughes, the Patient Safety Commissioner,” she explained. “Martha’s Rule is really an incredible policy story that came out of an extreme human tragedy. “Martha was on holiday with her family, when she had an everyday bike accident - the kind of accident that anyone who has a child has seen happen. But she fell awkwardly
not doing so was too great. We had such trust; we feel such fools.” The article that Merope wrote in The Guardian
was the most read on The Guardian website that year. “It really started a conversation about what could be done,” said Polly. Martha’s parents learned of Ryan’s rule in
Australia, which gives patients and families the right to trigger a clinical review, if they are worried that their concerns are not being heard. There was good evidence from Australia that this approach was successful and this helped to provide a model for the development of the new policy. “We hosted a roundtable and brought
Martha Mills
on the handlebar, suffering an injury to her pancreas… Merope and Paul spent the next five weeks taking it in turns sitting at her bedside in hospital. She suffered every conceivable possible complication. “She died at King’s College London, after a bank holiday weekend, following days and days in which her parents expressed their concerns and were not listened to – and that was the key insight. They were expressing concerns, they weren’t listened to, and they weren’t trusted with the information they needed to advocate for their child’s life.” Martha’s parents put all their faith and trust in the hospital but weren’t told that she had a serious infection. The patient notes referred to Merope as ‘an anxious mother’. Merope later shared her advice to other
parents in an article: “Be aware that much care in hospitals is less throughout the weekends and understand the damage done by the hierarchical patrician system. Everyone defers to the most senior consultant, if things go wrong – shout the ward down. In our case, the cost of
together people from across England and gathered support for this plan. One very wise hospital leader, right at the beginning, urged us to do something practical and implementable – something that can be done. We all knew that, at the heart of this problem, there was a cultural problem within the NHS, but culture change is very complex and very slow. It is the right thing to do in the wider context, but we wanted to do something that could result in demonstrable action now, to empower patients,” Polly continued. A policy paper was developed for Martha’s Rule, documenting the evidence about how similar rules have been implemented in Australia, America, and even in some hospitals in the UK. In September, last year, Merope went on the Today programme and told her story. “It was the detail, the humanity, and the articulation of a problem that I think many people relate to in hospitals – the feeling of not being treated as an equal partner in their care or not being listened to – that really cut through. At the same time, we published a paper setting out a proposal around Martha’s Rule and the evidence that it can save lives,” Polly explained. Within eight hours, the health secretary, at that time, Stephen Barclay, announced to the House of Commons that he would investigate
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