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Chris Subbe: Martha's Rule

Chris Subbe

Everybody has the right to call for help - even in hospital.

By the time this blog is published, there has probably been an announcement by the Department of Health about the implementation of the recommendations by the Patient Safety Commissioner about ‘Martha’s Rule’. Thirteen-year-old Martha Mills died in 2021 following a traumatic pancreatic injury and sepsis. Organisational culture and delays in escalation of her care contributed to her death.

Following a passionate campaign by her parents the Patient Safety Commissioner recommended that English hospitals should have the ability for patients and their families to escalate care directly to someone with the ability to look after critically ill patients, i.e. a Critical Care Outreach team. This service should be available 24/7, and in addition hospitals should find ways to capture the subjective wellbeing of patients in a more systematic way.

Chris Subbe

There are two responses: Recognition of the opportunity and fear of being overwhelmed.

When I talk about this topic with colleagues, I sometimes ask everybody in the room to raise their hand if they have ever been in hospital or had a relative or close friend admitted. I then ask them to keep the hand up if they were concerned about aspects of care that they witnessed. I ask them to keep their hand up if they went and spoke to a senior member of staff that they knew from previous work or as a colleague. And then I ask them whether they think that they added value to that care episode. About 80% of clinicians will keep their hand up to the end. I then say: ‘You have just used Martha’s Rule’.

Healthcare professionals add significant value to the care of loved ones by spotting things that can be improved and using their knowledge of the system to enable better, safer care. But importantly they use their knowledge of the person in the same way anybody would advocate for their loved one.

By law they are not given any extra rights. If is therefore difficult to see how they would be allowed to escalate the care of someone (who is not under their care) and other couldn’t. Martha’s Rule is little more than giving everybody the right to call for help that professionals are already routinely using.

The second response to the new policy proposal is often concern; concern that Critical Care Outreach teams and other clinicians will be called for trivial and unjustified concerns, down to complaints about the quality of the tea.

This type of service has been operating at scale in most of Australia and New Zealand for some time. And the innovative Mandy Odell has introduced the service as Call-4-Concern many years ago at the Royal Berkshire hospital in Reading. And she has published her experience over 7 years. There is thus data about the number and nature of calls.

Chris Subbe

Will there be many calls citing ‘Martha’s Rule’? Fortunately not and unfortunately not..

We know from published data that very few patients and family members will actually call. Often 1-2 per week or even less. And we know that very few will call even if they know the service exists and even if they are rightly worried: the threshold for raising concern is high. Activation of Critical Care outreach is often seen as a way of undermining hard-working nurses and doctors on the ward; patients don’t want to let their nurse down! We saw similar concerns when Critical Care Outreach teams were initially introduced. It took time for everybody working in the hospital to get used to the fact that it is ‘normal’ to escalate someone who is deteriorating to an experienced Outreach practitioner. We will have to see what modifications will be needed to normalise ‘Call-4-Concern’ for patients and families.

The equitable ability to escalate care has initiated an important public debate. But as always – it is just the beginning of a journey; and more research is needed.

In the meantime, Martha’s Rule could help to enshrine a universal right to call for help. Even in hospital.


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