Since campaigning for the patient safety initiative Martha’s Rule, I’ve received many messages from people who have invoked it, or wish it had been available to them. The ones I remember most vividly have been from doctors. They describe episodes when they themselves or their family members have been treated in hospital. In the ‘us’ and ‘them’ divide between clinicians and patients, they have suddenly become ‘them’ and have often felt powerless.

A doctor recently wrote to me about her husband, who was on a ward with complex empyema. Despite raising concerns and asking for him to be moved to the intensive care unit (ICU), she was stonewalled by a senior house officer. She eventually became desperate and, lacking any other agency, went down the corridor and banged on the doors of ICU, demanding a review. Her husband was immediately admitted, had four-hour surgery and escaped death from sepsis. As this occurred in Scotland, Martha’s Rule had not been implemented.

I called for Martha’s Rule in newspaper articles and on the radio because I wish it had existed when my 13-year-old daughter, Martha, was deteriorating on a ward. A previously healthy teenager, she was being treated for pancreatic trauma after she fell off her bike. She died a preventable death in August 2021 after mistakes were made at King’s College Hospital in London. In particular, the liver team was resistant to moving her to paediatric ICU even though she had a disseminated intravascular coagulation and was being treated for severe sepsis.

The day before Martha collapsed with a cerebral hypoperfusion, she had high fever, very low blood pressure, a racing heart, unexplained sepsis and a rash all over her body. Her Bedside Paediatric Early Warning System score merited immediate escalation. But she was kept on the ward. This was partly because the high-status liver consultants wanted to keep control and were dismissive of their colleagues in PICU. And partly because it was said that a critical care review would increase my anxiety. More than once I had said how worried I was about sepsis and septic shock, but I was ignored. I was never told Martha had sepsis. My own view of my daughter’s deteriorating condition was considered of no importance.

A nationwide change 

Martha’s Rule has been introduced at 143 hospital sites in England and Wales. It has a number of aspects but, in essence, means that patients, relatives and carers, noticing a patient’s deterioration, can trigger a review from a critical care outreach team. In Martha’s case, some of the nurses on the ward felt she should have been in ICU, but such was the hierarchy that their views weren’t heard – so it is important that Martha’s Rule can be invoked by staff (nurses and resident doctors) too. Similar initiatives exist around the world, notably Ryan’s Rule in Australia.

I could see there was an obvious need for such a mechanism but have been astonished at the positive results already achieved. With data gathered from the final months of 2024, the departing NHS England medical director, Stephen Powis, highlighted that “one in five clinical reviews triggered by Martha’s Rule” had led to “potentially life-saving changes in care … the initiative is starting to have a transformative effect in improving patient safety”. In September and October 2024 alone, 14 patients were transferred to intensive care after Martha’s Rule was deployed. Even those cases not involving an urgent review have improved treatment and communication.

I’m delighted that Martha’s Rule is already saving lives but it is also intended as a cultural intervention. I’m fully aware of the problems the NHS experiences with underfunding, short-staffing, crumbling infrastructure and clinician burnout. But it is important to underline that these were not the most important factors in the shocking care that Martha received. Cultural and status issues were at the heart of the catastrophe, and individual poor performance, too. 

Giving patients a voice 

Healthcare professionals know that many errors made in hospitals – there are far more mistakes than the public might want to know about – are to do with silo working, poor inter-team relations, steep hierarchies, lulls in concentration, insufficient training and doctors too junior or ill-equipped to be making important decisions. Such issues do not often get talked about in public but, given they exist, it is all the more crucial to give patients and those by their bedsides more of a voice, and more agency. Not to do so is dangerously neglectful of
patient safety.

At King’s there was not a named ‘responsible consultant’ who could have noticed Martha’s trends and whom I could have called when I became very worried. We saw a different consultant every day on Rays of Sunshine ward and over the bank holiday weekend, when Martha went into septic shock, the duty consultant went home at lunchtime, on call, leaving junior colleagues who failed to review her adequately. If it is the case that such staffing situations can happen in hospitals, it is obvious that doctors should be alert to what patients and family members are saying about a change in condition. I was the other ‘expert’ in the room when it came to Martha, but I wasn’t given a chance to save her.

At a Martha’s Rule meeting a month or so ago, one of the thoughtful doctors who is promoting and encouraging the initiative reported that Martha’s Rule was invoked in the case of a patient under his care. He was honest enough to admit that he bridled a little and felt uncomfortable. Senior doctors aren’t used to being challenged. In her book, Unheard, which considers how not listening to patients is ingrained in medicine, Dr Rageshri Dhairyawan recalls how it begins at the age of 18 or 19, when medics are encouraged to think of themselves as “separate to, and we believed slightly superior to, other university students”.

In 2009, an antecedent to Martha’s Rule, Call for Concern, was introduced at Royal Berkshire Foundation Trust. The pioneering nurse consultant responsible, Mandy Odell, has recalled that doctors pulled down posters for the service because they hated the idea of giving patients such power. When I called for Martha’s Rule, doctors on social media were convinced it would be used for trivial complaints. But it hasn’t been abused or overused, and patients and their families don’t deserve to be the subject of condescension. The data have proved how well it works.

Change for the better 

In the few years during which I’ve played a small part in the world of patient safety, I’ve met very many healthcare professionals who care passionately about introducing improvements, breaking down established cultures – making medicine less conservative. Most say everything is changing for the better and more resources are needed to speed up the process. But just as the very best doctors are the ones who never mind being challenged, so the most honest doctors are the ones who realise that problematic cultures still need to be tackled in medicine. However difficult the working conditions, and however varied the patients, the idea of more patient power needs to be embraced. 

Martha’s Rule is a modest contribution to a revolution of sorts. I call on the government to extend it to more hospitals and to Scotland, and for clinicians to welcome it and make sure their patients know all about it when they arrive in hospital. It’s a safety net that won’t be used very often, but it is vital that it’s there. If I had seen a poster on the wall, I would certainly have made the call and Martha might still be alive.