Patient safety
NHS is not in a great place – if lots of patients and families start asking for Martha’s Rule improvements, there needs to be more funding and more thought given as to how this will be resourced,” Dr. Wickins-Drazilova commented. “I think my main concern with Martha’s Rule
and potential barriers is: how are patients, parents and other carers supposed to know when a second opinion is needed and when to raise these concerns?” Decisions on observation and their analysis
are often not consented (unlike treatments), she pointed out. While treatments are discussed (for example when somebody switches from one medication to another), decisions about observations and the ordering of tests happen in the background. “I can share with you my own experience with being in intensive care for two days, several years ago. I thought everything went swimmingly on day one. I was deteriorating, but I thought the team was on the top of things. On day two, I had concerns about one member of staff that had communication issues. So, after I left the hospital and I recovered, I wrote a complaint. “That triggered an investigation. The NHS Trust
looked minute-by-minute at my care during those 48 hours and what they found was that, in day one, there were observations that were supposed to happen every hour, that the doctor ordered, but didn’t happen for several hours and they weren’t properly recorded…I had no idea, yet my husband is a retired nurse and he was next to me all the time. I was conscious and competent, and we had no idea how serious my condition was on day one. Had it not been for the incident on day two, we would have had no idea that I was close to dying on day one. Nobody really communicated to us, and we didn’t raise a concern – because we didn’t know.
I see the primary leadership accountability is to create a positive safety culture that advocates for raising concerns, learning from what has gone well and less well, and listening to the voice of colleagues,
and service users and their loved ones. Steve McManus, Chief Executive, Royal Berkshire NHS Foundation Trust
“I think a downside of Martha’s Rule is that patients and the families often don’t know and there is a power imbalance as well. In my experience, raising concern, as a patient or loved one in hospital, often leads to a breakdown of trust and break down of communication. My experience of when I raised concern about my child’s care in hospital was that I wasn’t listened to; I was just brushed off. In fact, the following day, the team went behind my back to my husband and raised concerns about my mental health. I think there are so many barriers, at the moment, with patients and families raising concerns.” She went on to discuss some of the solutions. In her view, Martha’s Rule will be successful if we: 1. Share patient notes with patients (or parents and other carers).
2. Train more doctors and other healthcare professionals (and train them also in humility rather than blind confidence).
3. Spend more money and resources on the NHS. 4. Improve training, guidance and accountability of NHS managers and leaders.
A legal perspective Kashmir Uppal, a Partner at Shoosmiths Solicitors, went on to discuss the legal
implications around Martha’s Rule, as well as the implications around the failures in care that led up to the drive for improvement. She explained that she had previously worked as a lawyer on the Bristol paediatric cardiac cases, in 1995 - one of the issues highlighted at this time was that parents felt their concerns were not listened to: “It is a sad state of affairs that we haven’t moved on much,” she commented.
Kashmir explained that a serious incident
report on Martha’s death said there were at least five occasions when she should have had a critical care review. She was known to have had sepsis, six days before she died – and, on the day of her rapid deterioration, she was known to be septic, but was not escalated to intensive care. The Inquest suggested two main reasons why Martha was not moved to intensive care: l Her BPEWS score reached 8, but unfortunately King’s College did not have an electronic early warning system – this would have automatically alerted PICU to Martha’s condition.
l She was not moved to critical care due to a communication breakdown between the team on the Liver ward and PICU.
For Martha’s Rule, implementation will take a phased approach. The first phase will focus on supporting the 143 hospital sites to devise and agree a standardised approach to all three elements of Martha’s Rule. It is expected to be in place by March 2025. The three elements are:
1. An escalation process will be available 24/7 at all the 143 sites, advertised throughout the hospitals on posters and leaflets, enabling patients and families to contact a critical care outreach team that can swiftly assess a case and escalate care if necessary.
2. NHS staff will also have access to this same process if they have concerns about a patient’s condition.
3. Alongside this, clinicians at participating hospitals will also formally record daily insights and information about a patient’s health directly from their families, ensuring any concerning changes in behaviour or
September 2024 I
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