Lottie W
Oct 27, 202311 min
Updated: Feb 21
In your upcoming medical school interviews, you will be expected to have a good level of knowledge on current NHS hot topics in the NHS.
Martha’s Rule is an upcoming topic of discussion in the NHS, as it is about to be rolled out across NHS hospital trusts following approval from government decision-makers.
For your UK medical school interviews, you may be expected to know about Martha’s Rule. This article will discuss everything you need to know about Martha’s case, including some example medicine interview questions and model answers for you to look at.
We will also explain how to tackle any question your medical school interviewer may give you on Martha’s Case, with links to the ethical considerations and impact on the NHS!
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Martha’s Rule is a patient safety initiative allowing patients and their families to request urgent independent clinical reviews within the NHS if they feel that their concerns are not being listened to.
It was created by the mother of a 13-year-old girl, Martha Mills, who died of sepsis following a number of failures by NHS doctors, who did not listen to the family’s concerns.
As of February 2024, Martha’s Rule has passed the proposal stage and has been accepted by the UK Health Secretary and NHS England.
From April 2024, Martha's Rule will be rolled out to at least 100 NHS sites in England.
Martha’s Rule mirrors a number of international systems for second-opinion medical reviews.
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Martha’s Rule is a patient safety initiative being rolled out to over 100 NHS sites across England in April 2024.
It allows patients and their families to summon an independent, urgent clinical review of a patient’s condition by a different team in the hospital.
It not only gives patients the right to ask for a second opinion but the power to trigger one.
It provides patients and families the power to gain a rapid second opinion on the patient’s condition and care, without them needing to seek this out themselves.
The NHS does not currently prevent patients from gaining second opinions on their care. In fact, the GMC states that doctors must respect this decision made by a patient or their family. However, this is not a legal, or protected right.
Often this is a slow procedure, with some second opinions needing to be organised by a GP, and therefore can be difficult for patients to request when in an emergency situation.
The recommendations of Martha’s Rule include:
The team giving a second opinion on patient care must be independent from the original treatment team.
This independent team must be reliable and qualified to assess the patient.
Awareness of this system must be raised, and it must be communicated clearly to patients.
This system should be adopted by NHS trusts as soon as possible
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Martha Mills was a previously healthy 13-year-old girl who died of sepsis following a bicycle accident in 2021.
After falling off her bicycle on holiday, the pressure of the handlebars pushed against her pancreas, which, in turn, pushed her pancreas against her spine, causing a laceration in her pancreas.
She was admitted to the hospital, where she quickly deteriorated and developed sepsis.
Doctors at the King’s College Hospital NHS Foundation Trust failed to act on sepsis markers, despite her mother’s alarm and concerns.
"If she'd been transferred properly and had appropriately been treated, the likelihood is she would've survived her injuries"
Her mother, Merope Mills, said that senior NHS doctors did not listen to her about Martha’s deteriorating condition, that she trusted the clinicians against her instincts, and that they “managed” her.
Martha passed away shortly after being transferred to the paediatric ITU. The coroner confirmed that Martha had died of sepsis.
Martha had not been transferred to intensive care early enough as indicated by her physical observations. The mistakes made by doctors in identifying and treating sepsis led to Martha’s death.
An inquest found that if she had been moved to intensive care sooner, she would have likely survived. The Coroner said: “If she’d been transferred properly and had appropriately been treated, the likelihood is she would’ve survived her injuries”.
Martha’s Rule aims to prevent this from happening again, such that concerned families can ask for independent staff to come and reassess the patient, in situations like Martha’s, where the family feel that their concerns are not being listened to by staff.
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Unfortunately, there is evidence that the NHS does not adequately protect patients or staff who whistleblow or challenge care decisions.
Martha’s rule aims to empower the family of patients to be able to advocate for their care and speak up if they believe that it is not satisfactory.
If patients and their families are encouraged to voice their concerns about their care, it should allow issues to be identified sooner. Perhaps the prospect of an independent team investigating this care will lead to these issues being addressed sooner.
Therefore Martha’s rule has the potential to improve patient safety.
In the UK, there's an issue with doctors not communicating well. A 2019 study showed that 22% of patients who had problems in the hospital believed it was because of bad communication between staff and patients.
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Martha’s Rule raises a number of complex ethical considerations for both patients and healthcare professionals.
The Doctor-Patient Relationship: the doctor-patient relationship is built on trust, and doctors have a duty of care for their patients. It is arguable that having the choice to request a second opinion suggests that doctors may not be trustworthy. This could damage the doctor-patient relationship, even for when patients have not requested a second opinion.
Patient Autonomy: Autonomy in the NHS allows patients to make decisions about their care. Martha’s Rule supports patient autonomy, by providing routes for patients to make.
Potential for abuse - Martha’s Rule has the potential to be abused by patients or their families. Systems must be in place to ensure that it is not used inappropriately.
Risk of delay to treatment - Asking for a second medical opinion may lead to necessary medical treatments being delayed, which risks the potential of patient harm
Patient Consent - there needs to be clear documentation regarding who can raise concerns about patient care through Martha’s Rule.
Hospital and Staffing Resources - the ethical issue of safe hospital staffing and patient resources may affect Martha’s Rule. We discuss this further in the Barriers to Martha’s Law section below.
Systems like that created by Martha’s Rule already exist internationally.
In Queensland, Australia, after the tragic death of Ryan Saunders from a missed streptococcal infection diagnosis, a protocol named Ryan’s Rule was established.
Australia has a medical protocol known as “Ryan’s Rule”. This allows relatives to dial a special number to request a Ryan’s Rule Review. Following this, a senior clinician attends and provides assistance.
Ryan’s Rule has been invoked over 10,000 times since its establishment in 2013.
The success of Ryan’s Rule in Australia has been noted by Health Secretary Steve Barclay, as ministers discussed the proposal of Martha’s Rule in September 2023.
The University of Pittsburgh introduced the Condition H(elp) system after the unfortunate passing of Josie King in 2001 due to hospital mistakes and communication issues.
This system allows patients to directly alert a quick-response team via an in-hospital emergency number.
Studies have indicated that this system has not been misused and even reduced heart attacks by 25% in a Jacksonville hospital.
In the UK, some hospitals have implemented the Call 4 Concern policy.
This approach provides patients with the means to alert a hospital's Critical Care Outreach Team if they notice unaddressed changes in their health.
The initiative is widely promoted throughout the hospital, with reminders even on bedside storage units.
A 2019 assessment in the Royal Berkshire noted that of 534 alerts, about 20% needed major medical actions.
As of February 2024, Martha's Rule has been backed by the Government, to be rolled out across NHS England.
Whilst the rollout of this policy begins in April 2024, there are a number of barriers which may affect how effectively Martha’s Rule can be implemented.
One of these barriers is resource allocation.
Even a small increase in the number of patients requesting second opinions through Martha’s Rule could lead to a massive increase in required resources. NHS resources and staff are already strained, and there are questions regarding whether the NHS has the capacity to meet the standards set in Martha’s Rule.
One suggestion made by the campaign of Martha’s Rule is that the hospital’s Critical Care Outreach team could be used as the independent team reviewing patients. Hospitals must consider whether this will compromise the safety of other patients requiring the Critical Care Outreach Team if their availability is reduced.
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In your UK Medical School Interviews, you can really impress your interviewers with your knowledge of Martha’s Rule, as it’s an upcoming NHS Hot Topic.
In answering interview questions regarding Martha’s Law, you should demonstrate your understanding of how the mistakes made by the doctors directly contributed to Martha’s death. You should recognise how these actions undermined the standards for doctors set by the GMC in the Good Medical Practice Guidance.
So, what mistakes did the doctors make?
Not transferring Martha to ITU at the time that it was first clinically indicated.
Misdiagnosis of a sepsis rash.
Not listening to Martha’s family’s concerns about her deterioration.
Junior doctors and nurses fail to challenge the decision-making of their seniors.
How do these mistakes undermine the GMC’s good medical practice for doctors?
The GMC states that doctors must take immediate action if they believe a patient is unsafe or deteriorating. The doctors in this case did not act quickly enough.
Doctors must provide a good standard of practice and care, with up-to-date professional knowledge and skill. Misidentification of the rash Martha developed was a serious error in the doctor’s skill, which was one of the contributing factors to her death.
Doctors are required to listen to, respect and respond to patient concerns. The doctors in this case did not listen to Martha’s mother's concerns that she was deteriorating.
Doctors must be candid and communicate effectively. In Martha’s Case, the doctors did not communicate with her family regarding the seriousness of her condition. This contributed to the distress of her family.
Martha's Rule is a new patient safety initiative in the UK that gives patients and their families the right to request a second opinion from a senior clinician if the patient's condition is deteriorating or they have serious concerns about their care.
Here is an example of why a patient or their family might invoke Martha's Rule:
A patient is admitted to the hospital with abdominal pain. The patient's condition deteriorates rapidly, but the doctors on the ward do not seem to be concerned and have arranged a scan for the upcoming week.
The patient's family is worried that the doctors are missing something, so they request a second opinion under Martha's Rule.
The second opinion doctor reviews the patient's case and sends them for an urgent CT scan of the abdomen, which reveals a bowel perforation. The patient is then sent to theatre for surgery, and given broad-spectrum antibiotics.
In this scenario, had the patient waited until the following week for a scan, they may have deteriorated rapidly and developed sepsis.
Other examples of why a patient or their family might invoke Martha's Rule include:
The patient is not satisfied with the explanation they have been given about their diagnosis or treatment options.
The patient feels that they are not being taken seriously by their doctor.
The patient is concerned about the potential risks of the proposed treatment.
The patient has had a bad experience with the healthcare system in the past.
The patient is from a minority group/BAME group and feels that they are not being treated fairly.
👉🏻 Read more: 280 Medical School Practice Interview Questions
What is Martha's Rule and what are the potential benefits and challenges of its implementation?
How would you explain Martha's Rule to a patient who is considering requesting a second opinion?
What steps would you take to ensure that a second opinion is obtained in a timely manner and that the patient's concerns are addressed?
How would you handle a situation where a patient requests a second opinion under Martha's Rule, but you believe that the second opinion may delay the patient's treatment and could have negative consequences for their health?
What are your thoughts on the ethical considerations surrounding Martha's Rule?
How do you think Martha's Rule could impact the relationship between patients and healthcare professionals?
What are some of the potential challenges that the NHS might face in implementing Martha's Rule?
How do you think Martha's Rule could impact patient safety in the NHS?
What are your thoughts on the role of patients and their families in decision-making about their healthcare?
How do you think Martha's Rule could impact the role of doctors in the NHS?
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Martha's rule is a new way for patients and their families to trigger an urgent clinical review from a different team if they are in hospital, are deteriorating rapidly and feel they are not getting the care they need.
Martha Mills, a healthy 13-year-old, tragically died of sepsis following a minor accident, leading to the proposal of Martha's Rule. Doctors failed to act on sepsis signs, which her family had raised concerns about.
Martha's Rule's recommendations include independent reviews, qualified assessors, heightened awareness, and prompt adoption by NHS trusts, aiming to improve patient care and safety.
Martha's Rule, by allowing patients to request second opinions, may raise concerns about trust in the doctor-patient relationship as it gives patients more control over their care decisions.
Ethical concerns include potential damage to trust, patient autonomy support, risk of misuse, treatment delays, and the need for clear documentation and resource allocation.
Martha's Rule empowers patients and families by enabling them to request independent assessments of their care, encouraging them to voice concerns when they believe care is unsatisfactory.
Australia has "Ryan's Rule," a formalised medical review system. It's been successful, with over 10,000 requests since 2013, serving as an inspiration for Martha's Rule in the UK.
A major barrier to implementing Martha's Rule is resource allocation. One suggested solution is to utilise Critical Care Outreach teams for the reviews, although concerns exist about potential impacts on other patients needing their services.
Yes, Martha's Rule may lead to treatment delays. Minimising delays involves clear documentation, efficient processes, and careful resource management to ensure timely care delivery.
To demonstrate understanding in medical school interviews, applicants should discuss Martha's Rule, its potential to transform patient care, its impact on the doctor-patient relationship, and the ethical considerations associated with its implementation.
👉🏻 Need to freshen up your knowledge of these important NHS Hot Topics?
Find everything you need to know on: The Charlie Gard Case, The Harold Shipman Case, The Francis Reports and Mid Staffordshire NHS Trust Failings and The Lucy Letby Case
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