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27 February 2024 | Comment | Article by Ruth Powell

What is “Martha’s Rule” and how will it impact patients, their families and NHS staff?


Following the announcement from the NHS that ‘Martha’s Rule’ will now be introduced across hospitals in England, Carys Lewis, solicitor in our Clinical Negligence team, explores how this will empower patients and families to request an immediate review should their or a loved one’s condition worsen.

All too often, our specialist clinical negligence lawyers are informed by patients and/or their families that concerns they raised during a hospital admission were sadly ignored. Frequently, we encounter situations where families repeatedly voice the same concern day after day, only to be reassured that it’s a “usual” presentation and that they would soon see an improvement. In some cases, their concerns are often ignored entirely, leading to devastating outcomes. Very sadly this is what happened to Martha Mills in 2021.

Martha’s story

Martha sustained a pancreatic injury after falling off her bike and was admitted to hospital. Martha contracted an infection while in hospital on 21 August 2021 and her condition deteriorated over a period of ten days. Initially, Martha developed a high temperature, diarrhoea, and low blood pressure. Within a few days she had begun to bleed heavily through the tube that was inserted in her arm and by 29 August, her symptoms had worsened and she was experiencing a racing heartbeat and a rash.

Her parents raised concerns about her deterioration several times. They explicitly raised a concern with hospital staff that she had sepsis and would develop septic shock. Her parents were told daily that her recovery was not in doubt and it was just a matter of time. It was noted in Martha’s medical notes that her mother was “very distressed.” Martha very sadly died on 31 August 2021 at the age of 13. Sepsis and refractory shock were noted as cause of death on her death certificate.

An inquest opened into Martha’s death on 3 September 2021. An inquest is a formal fact-finding investigation conducted by a coroner to identify the deceased and ascertain where, when and how they died. The inquest heard that there were several opportunities to refer Martha to intensive care during her hospital admission, all of which were missed. The inquest heard evidence that she should have been placed in a high dependency bed as early as 6 August – within 11 days of the bike accident. The coroner found that, had Martha been transferred to intensive care, this probably would have saved her life.

Martha’s parents have campaigned for the implementation of “Martha’s Rule”. The first phase of the Rule is to be implemented in at least 100 paediatric and adult acute NHS sites in England that are currently offering 24/7 critical care, from April of this year.  Previous research shows that there are thousands of avoidable deaths in the NHS each year and it is hoped that Martha’s Rule will help to save lives in the future.

What is Martha’s rule and how will it work?

Martha’s rule will enable patients and their families to seek an urgent independent clinical review of their/ a loved one’s condition if they feel their concerns are not being listened to by the treating team. The Rule is empowering for patients and their families and provides an opportunity for them to be heard. There are three strands to Martha’s Rule:

  1. All staff in NHS trusts must have 24/7 access to a rapid review from a critical care outreach team who they can contact if they have concerns about a patient. This means that nurses and clinical staff can escalate concerns themselves and seek a review.
  2. Patients, families, carers, and advocates must also have access to the same 24/7 rapid review from a critical outreach team if they are worried about someone’s condition. This is Martha’s Rule. The way in which families can access this review will be advertised around the hospital. The review will be conducted by professionals not involved in the patient’s current care and someone who is not part of their treating team.
  3. The NHS must implement a structured approach to obtain information on a daily basis from patients and their families directly relating to their condition.

Martha’s Rule is the latest of a series of measures the NHS has recently introduced to improve the way it identifies and documents any decline in a patient’s condition.  During the inquest into Martha’s death, the coroner heard that the bedside paediatric early warning scores system at the hospital where Martha died was still a paper-based system. In November 2023, a new early warning system was rolled out in the NHS to be used by staff treating children. The system is similar to that which in place for adults and newborn and maternity services and it is hoped that this new system will prevent similar devastating situations occurring in the future.

Welcomed change

Ryan’s Rule was implemented in Queensland, Australia in 2015. Ryan’s Rule was introduced following the death of Ryan, aged two, from toxic shock syndrome. Like Martha’s parents, Ryan’s parents raised concerns about his condition whilst he was in hospital and an inquest found that there was a failure to detect and respond to the infection in a timely manner. In 2021, Ryan’s Rule was used by patients or their families approximately 1,600 times and there are many examples of it being used successfully and emergency care being provided, ultimately saving lives.

Martha’s Rule is a welcomed change to practice in an acute setting (one in which a patient receives active but short-term treatment for a severe injury or illness).

There are already some measures in place within the healthcare system to seek a “second opinion”, however, these options are rarely communicated to patients. The General Medical Council, the public body that sets and enforces professional standards for doctors in the UK, states that all doctors must respect the patient’s right to seek a second opinion.

Often patients are not aware of their options and this is not communicated to them openly. Martha’s Rule provides an obligation for hospitals to advertise access to a clinical review within high traffic areas around the hospital using posters and other communication methods. Additionally, and most importantly, it grants patients and their families, not only the right to request a review, but also the authority to initiate such a review.

It is not unusual to see instances in our line of work where there has been a failure to seek a second opinion and to escalate care. From a patient safety perspective, it is hoped that the introduction of Martha’s Rule will reduce these instances and is a step forward in patient safety.

How can we help?

If your concerns have been ignored during a hospital stay or you suspect a missed or delayed diagnosis of sepsis, our expert clinical negligence solicitors are here to help. They can advise on whether you would be eligible to make a compensation claim. You can find out more on our dedicated sepsis claims page.

Author bio

Ruth is a Partner and Head of our Clinical Negligence Department. She has exclusively practised in clinical negligence since qualifying in 1995 and has a wealth of experience in complex and high value clinical negligence claims.

Disclaimer: The information on the Hugh James website is for general information only and reflects the position at the date of publication. It does not constitute legal advice and should not be treated as such. If you would like to ensure the commentary reflects current legislation, case law or best practice, please contact the blog author.

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