John Tingle, Assistant Professor in Law in the Birmingham Law School, says that there is a need for there to be formal right when there is a suspected deterioration of the patient's condition or where they have serious concerns.
Martha’s Rule has been a topic of intense discussion and debate in the media recently. Behind the rule is a sad and tragic story which strikes at the heart of NHS care delivery. Clinical failures and the death of a 13-year-old girl. The Guardian Newspaper reporting the Coroner’s Inquest proceedings stated that Martha would have been likely to have survived if moved to intensive care. The report states that,” … Martha Mills would probably have not died of sepsis had King’s College hospital doctors had heeded warnings.”
Martha’s mother, Merope Mills has recounted her experiences and the events that unfolded in a foreword to a recently published report by Demos, a policy think tank. She talks in detail about what happened, her regrets and what should happen next to stop the same tragic events happening to other people. She wishes to improve NHS patient safety and our health system. She talks about, silo thinking, poor interdepartmental relations, team reputations and so on. She states: “I was talked to, rather than listened to.”(p.5)
The NHS needs to do more to develop a patient safety culture. Much more needs to be done to give them, their relatives, carers, a firm platform from which to seek more help and to appropriately challenge what is going on if that need arises.
John Tingle - Assistant Professor in Law.
Tingle goes on to explain that there is an acceptance that some degree of error in health care delivery is always going to be inevitable. Nobody is infallible. Health care can be complex and is dependent on human decision making and interaction. What we can do however is to try and successfully manage risk in by developing a proper patient safety culture. Merope in her foreword talked about the patient safety issues she saw.
However, history has not served the NHS well when it comes to patient safety culture development. Unfortunately, the NHS has poor form when it comes to implementing the improvement recommendations made from past patient safety investigations and to changing practice. History has not served the NHS well in this regard. Patient safety crises events continue to occur at an alarming rate with often the same or similar errors being repeated. Mid Staffordshire, Shrewsbury and Telford, East Kent are to name but just a few cases. In the year 2000 the Department of Health published, Organisation with a Memory highlighting major patient safety issues, in 2023 many of them are still with us. Hospitals are at various levels of patient safety maturity across the NHS.
The NHS has a long history of trying to grapple with patient safety issues and not all is doom and gloom. There have been successes as well as failures. However, the failures do tend to eclipse the successes. We do have a good knowledge of patient safety issues but there is a glaring, ‘implementation gap.'
John Tingle suggests that the way forward is to adopt proposals by Demos and Merope, there are good models of doing what is recommended overseas, Ryan’s Rule and in the UK, Call 4 Concern. There is not a sufficiently developed, mature NHS wide patient safety culture to stop another tragic situation like Merope describes from happening again. We urgently need Martha’s rule formally implemented in the NHS.
