Latest news with #Martha'sRule
Spectator
01-07-2025
- Health
- Spectator
Martha's Rule should be a model for changing the NHS
What do we really need to change about the NHS? Later this week we will finally get the NHS plan from Health Secretary Wes Streeting which, like all the other big reforms before, promises to make the health service fit for the future and focused on patients. Streeting has been more articulate than many previous ministers about the failings of the current setup, saying the NHS today is often organised around the needs of the system, rather than the people it is meant to serve. One of the most pernicious aspects of this is the way the health service deals with mistakes. Streeting has already trailed 'pioneering AI technology' in the new plan which he says will 'rapidly analyses healthcare data and ring the alarm bell on emerging safety issues'. He hopes it could stop scandals like Mid-Staffs, or the many maternity units still under investigation for dreadful care. This week we also learned that the first six months of the Martha's Rule scheme, which allows families of patients to request an urgent second opinion from a critical care outreach team, has led to changes in care for 465 patients. Martha Mills died of sepsis in 2021 after medical staff repeatedly overlooked her family's concerns about her deteriorating condition and failed to admit her to intensive care. The parents of the 13-year-old campaigned after her death for this right to an urgent second opinion. Martha's Rule is one of those changes that really does show there is a way of changing the way a system runs so that people don't die just because busy medics refuse to have a second think about the decisions they have made. What was alarming for her family, who of course knew best what Martha was like, was that their concerns were largely dismissed as the typical anxieties of overwrought parents, rather than something the healthcare team might want to pay heed to. That dismissal of concerns is a regular problem throughout the NHS, which still adopts a very patrician view of patients and their relatives. A new AI system will not in fact be spotting many things that haven't already been highlighted by human voices. One of the great scandals of Mid Staffs was that so many people had raised concerns: doctors had tried to raise the alarm about what was happening in A&E, and relatives had been campaigning about the treatment and deaths of their loved ones for years. There was not an absence of concern. What was lacking was anyone paying attention to it. Similarly in maternity care, women in pain who are worried about their baby's movements or who have an instinctive feeling that something is going wrong are often dismissed as making a fuss. On a wider scale, we have long known that there are serious systemic issues in maternity, but the system is taking even longer to acknowledge and address those issues. Often relatives campaigning after a death are characterised as being driven mad by grief – and therefore easier to dismiss as being wrong. It is possible to be in the pain of bereavement and entirely right, just as it is possible to be driven mad by the system that repeatedly tells you that you were wrong about the things you saw written down in your child's medical notes (which have mysteriously gone missing), or about your attempts to raise the alarm with staff. Perhaps removing the human from the equation might help: will senior staff, Trust leaders and politicians listen to the warnings produced by an algorithm? Even if they find it harder to dismiss those results, it's worth pointing out that AI has not advanced sufficiently to pick up the signs of a toxic culture in a working environment or across a system. But we already know that the NHS does have a toxic culture when it comes to mistakes. Perhaps Martha's Rule will help shift that culture a little: not much else has before now.
The Independent
26-06-2025
- Health
- The Independent
Early diagnosis of sepsis faces ‘ongoing challenges'
The Health Services Safety Investigations Body (HSSIB) has identified "ongoing challenges" in the early diagnosis of sepsis, labelling it an "urgent and persistent safety risk" in the UK. HSSIB's reports detail three cases where patients suffered severe harm or death due to delayed sepsis recognition, citing issues such as delayed medication, lack of doctor capacity, and inadequate patient transfers. A recurring concern highlighted by HSSIB is that family members are often not listened to when they express worries about a loved one's deteriorating condition, which can delay critical interventions. Experts, including the UK Sepsis Trust, advocate for swift diagnosis, consistent public awareness of symptoms, and the implementation of a standardised " sepsis pathway" to improve patient outcomes. NHS England states it is supporting initiatives like Early Warning Systems, Martha's Rule, and patient wellness questionnaires to aid in early deterioration detection and empower patients and their families to raise concerns.
Wales Online
17-06-2025
- Health
- Wales Online
Bethan had a brilliant and full life ahead of her but it was taken away. It could so easily have been avoided
Bethan had a brilliant and full life ahead of her but it was taken away. It could so easily have been avoided 'It is heartbreaking for us to know that with appropriate treatment, Bethan would not have died... We now hope to receive an apology from the health board' The family of 21-year-old Bethan James, whose death could have been avoided, have slammed a health board for failing to take accountability. The daughter of cricket star Steve James was admitted to hospital on February 8, 2020 and died on February 9. An inquest into her death heard that she died of sepsis and pneumonia, which was complicated by the immune suppressing effects of Crohn's disease. However during the inquest's conclusion on Tuesday coroner Patricia Morgan said that Bethan likely 'would not have died' if medics acted appropriately sooner. The conclusion at Pontypridd Coroner's Court followed three days of evidence earlier this month. It included a statement from Bethan's mother, Jane, who detailed how she believed her daughter had been dismissed multiple times by hospital medics before her death. An expert witness had also shared that he believed Bethan's life could have been saved. Following the conclusion Steve and Jane delivered an emotional and scathing statement, which was read out to the press by their advocate Richard Booth KC. Bethan James was just 21 when she died. She hoped to teach others about Crohn's The speech outlined the family's "indescribable" grief, before going on to reveal how an inquest into Bethan's death was refused three times before it was finally permitted. Article continues below The family, who live in St Mellons in Cardiff, shared that they are "glad" that the Welsh Ambulance Service Trust (WAST) accepted "some of their failings", but said they are "deeply disappointed" that Cardiff and Vale University Health Board (CVUHB) "has not done the same". The called for the health board to apologise and for healthcare professionals to "admit their mistakes" so that "lessons can be learnt". The family pleaded with the Welsh Government to implement Martha's Rule across the NHS in Wales. This is a patient safety initiative in English NHS hospitals, granting patients and their families the right to request an urgent review by a critical care outreach team if they are concerned about a patient's deteriorating condition. WalesOnline has asked WAST, CVUHB and the Welsh Government to comment. The statement was read out by the family's advocate (Image: John Myers ) Here is the family's full statement: "It is over five years since Bethan died, but the pain and grief are still indescribable and will always be so. Our hearts are broken forever and we miss her dreadfully. "We know that Bethan should not have died and we have always felt that she was let down by the healthcare professionals who should have been there to help and support her. "Bethan was just too kind and caring; never one to make a fuss or complain about anything. And even when we tried to advocate on her behalf we were dismissed and we were not listened to by the doctors and nurses. "Although it has taken over five years - and they (the family) threatened judicial review to secure an inquest for Bethan after three refusals to hold an inquest - we are pleased His Majesty's area coroner Mrs Patricia Morgan permitted a comprehensive investigation of the circumstances leading up to Bethan's death, involving three days of evidence. "We note the coroner's conclusion this morning that there were a number of delays which contributed to Bethan's death. It is heartbreaking for us to know that with appropriate treatment, Bethan would not have died. "At 21 and just finishing her journalism degree our beautiful Bethan had a brilliant and full life ahead of her, but it was taken away by a catalogue of errors that could so easily have been avoided by etter listening, understanding, recognition and actions by healthcare staff. "Sepsis is still not spotted quickly enough and this was a tragic example. "We are glad that the Welsh Ambulance Service NHS Trust has at least admitted some of their failings, but we are deeply disappointed and distressed that the Cardiff and Vale University Health Board has not done the same. "It has become a cliche that the NHS is broken, but this was a case in point because the care given to Bethan was simply unacceptable. "We now hope to receive an apology from the health board." You can read more from the inquest here: Parents Steve and Jane James outside Pontypridd coroner's court (Image: John Myers ) The statement continued: "Suffering from pneumonia - not that we were told this - and against her background of Crohn's disease, unable to tolerate oral antibiotics without being sick. "Bethan should have been admitted to hospital long before the day she died, but on each of the five occasions when she attended hospital in the last two weeks of her life, we felt the general plan was to send her home as quickly as possible simply because there was not space for her. "In her sixth and last hospital attendance on the evening of Saturday, February 8, 2020, this culminated in Bethan not being admitted to the resuscitation unit swiftly enough and therefore not receiving the critical care she so desperately required "As a family we hope that this never happens to another family in the future. "But for that to be the case sepsis training and recognition of symptoms need to improve dramatically. Equally as importantly, healthcare staff need to admit their mistakes so that lessons can be learnt. "We have observed with interest the imposition of Martha's Rule in England named after Martha Mills who also died of sepsis when her family's concerns were not listened to. "Martha's Rule is a major patient safety initiative providing patients and families with a way to seek an urgent review if they or their loved one's condition deteriorates and they are concerned they are not being responded to. "This now provides parents in England with a route to a critical outreach second opinion. "We urge the Welsh Government to implement Martha's rule across the NHS in Wales so that needless and tragic deaths like Bethans might be avoided." Article continues below
Glasgow Times
11-06-2025
- Health
- Glasgow Times
No disciplinary sanction for doctor's ‘grave' failures in care of Martha Mills
Professor Richard Thompson did not refer Martha Mills, 13, to intensive care despite her displaying several high-risk indicators of sepsis. The on-call consultant also chose not to return to London's King's College Hospital to assess her in person as her condition deteriorated. A Medical Practitioners Tribunal Service (MPTS) panel sitting in Manchester had ruled those omissions were misconduct, which they described as 'particularly grave', and found his fitness to practise was impaired. However, on Wednesday the tribunal decided there were 'exceptional circumstances' which justified taking no further action against the world-renowned paediatric liver specialist. Martha had been an inpatient on the hospital's Rays of Sunshine Ward after she suffered a serious injury to her pancreas when she slipped while riding a bike on a family holiday in Wales in July 2021. Weeks later she experienced a fever and increased heart rate, followed by more spikes in her temperature before the consultant hepatologist saw Martha on his morning ward round on Sunday August 29. Prof Thompson left the hospital at 3pm, but was phoned at home two hours later by a trainee doctor, who gave an update on Martha's condition. Medical records showed she had deteriorated over the course of the afternoon, and into the early evening, with a drop in her blood pressure, the appearance of a new rash and increases in heart rate, respiratory rate and body temperature. Tribunal chairman Robin Ince noted that by 5pm there were 'several high-risk indicators' as set out in the Nice guidelines relating to sepsis. The duty registrar called Prof Thompson again at 8.30pm because of ongoing concerns over Martha's fever, but she was kept on the ward despite the continued presence of moderate to high-risk indicators and the absence of meaningful clinical improvement. Following the death of their daughter Martha, Merope Mills and Paul Laity campaigned for the creation of Martha's Rule (Family handout/PA) Martha collapsed on August 30 and was moved to intensive care before she was transferred to London's Great Ormond Street Hospital, where she died in the early hours of August 31. Announcing its conclusions on Wednesday, Mr Ince said: 'Professor Thompson has done everything possible to address his failings. 'The tribunal considered that the best way to repair any harm caused by his failings would be for him to continue to provide his specialist expertise at home and abroad. 'To now – some four years after the index event – remove Professor Thompson from practice, even for a short period of time, for one single lapse of judgment in an otherwise exemplary career would, in the tribunal's view, be akin to punishment which is not the role of the MPTS.' Among the 'exceptional circumstances' cited were that there was no allegation or evidence that Prof Thompson either caused or contributed to Martha's death. There were also systemic failings regarding how the ward functioned at the time with regard to referrals to the paediatric intensive care unit, said the tribunal. Mr Ince said: 'A sufficiently clear message has already been sent to the profession and to the public – that even such an experienced doctor as Professor Thompson could still make serious errors of clinical judgment for which he will be called to account. 'The public would be aware that this finding would remain a stain on Professor Thompson's reputation for the rest of his life.' At a 2022 inquest into her death, a coroner ruled that Martha would most likely have survived if doctors had identified the warning signs and transferred her to intensive care earlier. Martha's mother, Merope Mills, an editor at The Guardian, said she and her husband, Paul Laity, raised concerns about Martha's deteriorating health a number of times but these were not acted on. The couple later successfully campaigned for Martha's Rule to give patients, families and carers the chance to easily request a second opinion from a senior doctor in the same hospital in the event of a suspected deterioration or serious concern. Giving evidence, Prof Thompson told the MPTS hearing that he no longer provided in-patient care because he began to 'doubt my own judgment' after the tragic events. He said he felt 'deep remorse' for Martha's death but did not believe he made any errors in her case, as he denied all the allegations brought by the General Medical Council (GMC). The tribunal heard he had since completed a training course relating to the management of sepsis and a deteriorating child in paediatric care. His barrister, Ben Rich, said Prof Thompson has been a dedicated doctor and specialist for nearly 40 years and had never previously been investigated by a regulator. He said he had a reputation as a 'hard-working and outstanding clinician and researcher, who has an international reputation as one of the leading paediatric liver specialists in the world'. Mr Rich urged the tribunal members to impose an order of conditions involving supervision on Prof Thompson's registration, but the panel disagreed and said such a measure would be 'unnecessary and artificial', as they opted to take no further action. Christopher Rose, for the GMC, said that Prof Thompson should be suspended to send a message to the wider public and the wider profession, given the seriousness of the failings found. The tribunal had cleared Prof Thompson of the GMC's claims that he gave 'outdated, misleading' information on Martha's condition to a consultant colleague in the intensive care unit, and that he failed to mention her rash. In ruling his fitness to practise was impaired, Mr Ince said: 'There had been a significant potential risk of harm to Martha and it was appropriate to send a message to the profession as to the importance of following the basic and fundamental principles as set out in good medical practice so as to ensure that the potential risks of an adverse outcome are always taken into account.'
Western Telegraph
11-06-2025
- Health
- Western Telegraph
No disciplinary sanction for doctor's ‘grave' failures in care of Martha Mills
Professor Richard Thompson did not refer Martha Mills, 13, to intensive care despite her displaying several high-risk indicators of sepsis. The on-call consultant also chose not to return to London's King's College Hospital to assess her in person as her condition deteriorated. A Medical Practitioners Tribunal Service (MPTS) panel sitting in Manchester had ruled those omissions were misconduct, which they described as 'particularly grave', and found his fitness to practise was impaired. The tribunal considered that the best way to repair any harm caused by his failings would be for him to continue to provide his specialist expertise at home and abroad Tribunal chairman Robin Ince However, on Wednesday the tribunal decided there were 'exceptional circumstances' which justified taking no further action against the world-renowned paediatric liver specialist. Martha had been an inpatient on the hospital's Rays of Sunshine Ward after she suffered a serious injury to her pancreas when she slipped while riding a bike on a family holiday in Wales in July 2021. Weeks later she experienced a fever and increased heart rate, followed by more spikes in her temperature before the consultant hepatologist saw Martha on his morning ward round on Sunday August 29. Prof Thompson left the hospital at 3pm, but was phoned at home two hours later by a trainee doctor, who gave an update on Martha's condition. Medical records showed she had deteriorated over the course of the afternoon, and into the early evening, with a drop in her blood pressure, the appearance of a new rash and increases in heart rate, respiratory rate and body temperature. Tribunal chairman Robin Ince noted that by 5pm there were 'several high-risk indicators' as set out in the Nice guidelines relating to sepsis. The duty registrar called Prof Thompson again at 8.30pm because of ongoing concerns over Martha's fever, but she was kept on the ward despite the continued presence of moderate to high-risk indicators and the absence of meaningful clinical improvement. Following the death of their daughter Martha, Merope Mills and Paul Laity campaigned for the creation of Martha's Rule (Family handout/PA) Martha collapsed on August 30 and was moved to intensive care before she was transferred to London's Great Ormond Street Hospital, where she died in the early hours of August 31. Announcing its conclusions on Wednesday, Mr Ince said: 'Professor Thompson has done everything possible to address his failings. 'The tribunal considered that the best way to repair any harm caused by his failings would be for him to continue to provide his specialist expertise at home and abroad. 'To now – some four years after the index event – remove Professor Thompson from practice, even for a short period of time, for one single lapse of judgment in an otherwise exemplary career would, in the tribunal's view, be akin to punishment which is not the role of the MPTS.' Among the 'exceptional circumstances' cited were that there was no allegation or evidence that Prof Thompson either caused or contributed to Martha's death. There were also systemic failings regarding how the ward functioned at the time with regard to referrals to the paediatric intensive care unit, said the tribunal. Mr Ince said: 'A sufficiently clear message has already been sent to the profession and to the public – that even such an experienced doctor as Professor Thompson could still make serious errors of clinical judgment for which he will be called to account. 'The public would be aware that this finding would remain a stain on Professor Thompson's reputation for the rest of his life.' At a 2022 inquest into her death, a coroner ruled that Martha would most likely have survived if doctors had identified the warning signs and transferred her to intensive care earlier. Martha's mother, Merope Mills, an editor at The Guardian, said she and her husband, Paul Laity, raised concerns about Martha's deteriorating health a number of times but these were not acted on. The couple later successfully campaigned for Martha's Rule to give patients, families and carers the chance to easily request a second opinion from a senior doctor in the same hospital in the event of a suspected deterioration or serious concern. Giving evidence, Prof Thompson told the MPTS hearing that he no longer provided in-patient care because he began to 'doubt my own judgment' after the tragic events. He said he felt 'deep remorse' for Martha's death but did not believe he made any errors in her case, as he denied all the allegations brought by the General Medical Council (GMC). The tribunal heard he had since completed a training course relating to the management of sepsis and a deteriorating child in paediatric care. His barrister, Ben Rich, said Prof Thompson has been a dedicated doctor and specialist for nearly 40 years and had never previously been investigated by a regulator. He said he had a reputation as a 'hard-working and outstanding clinician and researcher, who has an international reputation as one of the leading paediatric liver specialists in the world'. Mr Rich urged the tribunal members to impose an order of conditions involving supervision on Prof Thompson's registration, but the panel disagreed and said such a measure would be 'unnecessary and artificial', as they opted to take no further action. Christopher Rose, for the GMC, said that Prof Thompson should be suspended to send a message to the wider public and the wider profession, given the seriousness of the failings found.
