31 January 2024

Martha's Rule: Early intervention protecting patients and clinicians



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Early intervention should be an automatic right if hospital care is of concern and a patient's condition deteriorates.
UK Food, Drugs, Healthcare, Life Sciences
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Following a commitment by the UK Government to introduce Martha's Rule, recommendations for its effective implementation have been put forward by the Patient Safety Commissioner for England to the Secretary of State for Health and Social Care (Secretary of State).

The Patient Safety Commissioner and the Parliamentary and Health Service Ombudsman have supported the introduction of a rule, such as Martha's Rule, so as to aid the obtaining of a second medical opinion, by this being an automatic right when hospital care is of concern and a patient's condition is deteriorating.

This approach would allow early intervention, which may avoid harm to patients, and derives from the committed efforts of the parents of Martha Mills, who called for such a rule intended to help improve patient safety after an inquest determined that their daughter, Martha, would likely have survived had doctors heeded the family's concerns.

To aid a safer culture in the health service and reduce risk of harm to patients, the Patient Safety Commissioner has recommended to the Secretary of State that there should be (by way of a summary):

  1. A "structured approach to obtain information relating to a patient's condition directly from patients and their families at least on a daily basis".
  2. An ability for "all staff in those Trusts" to "have 24/7 access to a rapid review from a critical care outreach team who they can contact should they have concerns about a patient".
  3. An ability for "all patients, their families, carers and advocates" also to "have access to the same 24/7 rapid review from a critical care outreach team". The profile of this team having been elevated both around the hospital and nationally, with similar set ups in each hospital.

These recommendations were developed having held policy 'sprint' sessions and meetings outside of those with key stakeholders.

In terms of the practicalities, a similar set up at Royal Berkshire NHS Foundation Trust (and subsequently applied by other trusts), which has a 'Call 4 Concern (C4C)' scheme provides an indication as to the positive effects of such a rule. C4C is an escalation system that allows patients and families to call or bleep a hospital's critical care outreach team if they are concerned about a change in the patient's condition which they feel has not been recognised. In particular, C4C should be contacted directly if:

  1. A "noticeable change in the patient occurs" and the patient or family/carer "feel that the health care team is not recognising" the concern.
  2. The patient or family/carer "feel there is confusion over what needs to be done for the patient" and "clear information about what is happening" is needed.
  3. There are "ongoing concerns" by the patient or family/carer despite having spoken with the ward nurse or doctor.

Royal Berkshire Hospital has posters in prominent positions around the hospital, so as to make all aware of this option and the feedback has been positive.

A response to the Patient Safety Commissioner's recommendations and a timetable as to implementation of Martha's Rule by NHS trusts in England is awaited.


With effective implementation, as has been seen in Australia under Ryan's Rule, this should further improve the quality of care provided to patients, where there is concern.

Not only should this support the instincts of those caring for the patient and those loved ones who know the patient best, but it may also lead to a more collaborative approach to patient care.

With patient care and patient voice at its heart, and with the opportunity to decrease financial pressures and preserve resources by making better decisions earlier, the introduction of Martha's Rule would be a welcome development.

This recommendation to improve patient safety, which may also reduce subsequent complaints and claims, is a positive step. It accords with supporting the patient voice and encouraging freedom to speak up. What will be needed, if supported by the Secretary of State, will be reassurance that the critical care outreach team is truly independent in reaching its decision when recommending options.

Understanding the views of those at the heart of a potential patient safety incident, via implementation of such a rule, would surely aid the maintaining, as opposed to restoring, of trust.

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