Martha’s rule

Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on X: @nadafkhan

Merope Mills’ description of the death of Martha, her 13 year old daughter, is a raw and harrowing account of the mistakes doctors made that led to Martha’s deterioration and ultimately her death.¹  In hospital with a pancreatic injury following an innocuous bicycling injury, Martha developed a severe infection, then sepsis, then septic shock, and her care was not appropriately escalated to the paediatric ICU.  Mills describes how her concerns were not listened to, and blames the hierarchical, patrician system in hospital whereby ‘the consultants swooped in, and were ostentatiously deferred to by the junior doctors’.  She wants us to take one of many lessons from Martha’s story, including introducing a mechanism to enable concerned patients or carers to challenge clinicians.  Mills named this ‘Martha’s Rule’, a process to formalise asking for a second opinion from a different team if a patient or close friend or relative is worried that the patient is deteriorating without an adequate response.²

A ‘batline’ to a second opinion

The concept of a Martha’s rule, or a ‘Batline’ to a second clinical opinion, has been trialled around England and internationally.  One such patient-led escalation process is Ryan’s Rule, which was rolled out across all hospitals in Queensland, Australia after the death of Ryan Saunders, a two-year old child, from toxic shock syndrome.  The three-step process of Ryan’s Rule involves firstly discussing concerns with a nurse or doctor, but if the result is not satisfactory, then talking to the charge nurse.  If the outcome of that discussion is not satisfactory, patients or their carers can call a governmental hotline to formally request a clinical review from an independent senior medic or nurse.³  A multi-site evaluation of Ryan’s Rule amongst surgical patients demonstrated that the rule was used amongst 334 surgical patients from 2016-2021, and for the majority (74%), the original treatment plan did not change after review.  Only seven patients had their care escalated and two cases were transferred to the intensive care unit, which are small numbers, but likely very meaningful to the patients and families involved.  Another audit of Ryan’s rule in one hospital between 2015-2017 concluded that again, a small minority of patients, just nine out of the 57 patients, were transferred to another hospital or a higher acuity ward.  One of the main outcomes of the study was that patients didn’t feel heard, or listened to about their concerns, with most issues being resolved through better communication.⁴

A similar programme was introduced at the Royal Berkshire Hospital in 2010 as ‘Call 4 Concern’, a system where patients or their families could directly contact the hospital critical care outreach team.⁵  Call 4 Concern has been rolled out amongst several other hospitals across the UK, where the system is billed as a patient safety initiative, and it would be interesting to see a multi-site evaluation of the programme to fully understand the impact these programmes are having on clinical outcomes and patient and carer experiences.

What are the experiences of clinicians, who may be hesitant to implement such rules into practice?  The authors of one of the audits of Ryan’s rule note the ongoing reluctance amongst some healthcare professionals to accept patient-led escalation processes due to concerns around misuse of the system and call-outs for minor issues rather than serious clinical deterioration, which was reflected in an early evaluation of ‘Call 4 Concern’ with concerns that the service would be inundated with inappropriate calls.  The experience from the Royal Berkshire, however, was that workload was not significantly increased by the scheme, and that some members of the critical care outreach team welcomed the positive impact on patient empowerment.⁵

What does this mean for general practice?

How would a concept like Martha’s Rule work in general practice?  GPs and other members of the general practice team can fail to recognise signs of clinical deterioration, or miss or delay a diagnosis, an increasing concern with greater use of telephone and remote consultation approaches.  In most practices, patients can vote with their feet and seek a second opinion from another GP, or present to A&E with any immediate concerns about clinical deterioration.  The GMC asserts that doctors should ‘respect the patient’s right to seek a second opinion’, and although this is not a legal right, I suspect there are only very few cases where a GP would refuse the right for a second opinion from another GP or secondary care colleague.  After all, GPs are human and subject to cognitive biases that can lead to diagnostic and treatment errors.  And although general practice is not run in the same hierarchical (and possibly increasingly outdated) firm-based structure as hospital teams, when confirmation bias leads to diagnostic errors early in the treatment pathway, diagnostic momentum can mean that other clinicians accept these incorrect diagnoses, perhaps more so when the initial diagnosis has been made by a more senior GP.⁶  The current call for Martha’s Rule is focussed on hospitals and not general practice, but it will be interesting to see what lessons can be learned and possibly transferred to primary care settings.

The tensions between patients and clinicians in post-modern medicine

The shift in authority from the learned clinician to the well-informed, sapient patient is one of the hallmarks of post-modern medicine.⁷  Muir Gray told us in 1999 that we need to address the empowerment of patients in an evolving medical climate.  The era of viewing patients as ‘hopelessly uninformed’ must surely be over, but we will need to face and find solutions to address the potential tensions between rising patient empowerment and the existing frameworks we practice medicine within.² Martha’s Rule is a call to hear and recognise the patient or carer’s voice alongside our best medical practice, and to prevent another tragedy like the death of Martha Mills.

References

1. Mills M. ‘We had such trust, we felt such fools’: how shocking hospital mistakes led to our daughter’s death. The Guardian. 2022.
2. Curtis PW, C. Martha’s Rule: A new policy to amplify patient voice and improve safety in hospitals. London; 2023.
3. Flynn DE, Flynn H, Gifford S, Smith K. Can you hear me? Analysis of a Queensland patient-initiated escalation process and the importance of communication in surgical care. ANZ J Surg. 2022;92(6):1371-6.
4. Dwyer TA, Flenady T, Kahl J, Quinney L. Evaluation of a patient and family activated escalation system: Ryan’s Rule. Aust Crit Care. 2020;33(1):39-46.
5. Odell M, Gerber K, Gager M. Call 4 Concern: patient and relative activated critical care outreach. Br J Nurs. 2010;19(22):1390-5.
6. Doherty TS, Carroll AE. Believing in Overcoming Cognitive Biases. AMA J Ethics. 2020;22(9):E773-8.
7. Gray JA. Postmodern medicine. Lancet. 1999;354(9189):1550-3.

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