Intended for healthcare professionals


Martha’s rule: a hospital escalation system to save patients’ lives

BMJ 2023; 383 doi: (Published 09 October 2023) Cite this as: BMJ 2023;383:p2319

Linked Editorial

Martha’s rule and patients’ rights to a second opinion

  1. Merope Mills, executive editor
  1. The Guardian

When a patient is deteriorating but no one is listening, Martha’s rule will guarantee a second opinion. Martha’s mother, Merope Mills, calls for doctors and nurses to embrace its implementation

My daughter, Martha Mills, died a few days before her 14th birthday in the summer of 2021. It was a preventable death. She was a happy, healthy child being treated for pancreatic trauma at King’s College Hospital, London, after she fell off her bike; no other child on record at the hospital has died of her injury.1 An inquest and two investigations have concluded that, on more than one occasion, she remained on Rays of Sunshine ward—a specialist location for treating the injury—when she should have been escalated to the paediatric intensive care unit, where a bed was available. King’s College Hospital has admitted breach of duty of care. Martha died of septic shock, six days after doctors on the ward recognised that she had severe sepsis.

I have spelt out in detail the mistakes that led to Martha’s death, failures that were both organisational and individual. I’ve written in the Guardian2 and spoken on BBC Radio 4’s Today programme.3 Countless doctors and nurses have been in touch with me to express sympathy and support—both in response to the circumstances of my daughter’s death and following my call, at the beginning of September this year, for Martha’s rule, a patient and family activated escalation system modelled on Call 4 Concern and international equivalents.

Martha’s rule is now to be introduced across hospitals in England; meetings are being held as I write to work out the specifics of implementation. With the help of effective promotion on wards, it should enter the everyday lexicon of patients.

I realise its introduction has come at a time of crisis in the NHS. But as many supportive doctors have told me, such an escalation system, which guarantees a second opinion, protects patients and overstretched healthcare professionals alike. Doctors and nurses are under great pressure, but this is exactly when Martha’s rule is needed most.

The wide support from medical professionals means an enormous amount to me—in part because it shows that they trust my account of what happened to Martha (a factual account informed by King’s and expert consultants). It might be easier for these clinicians to dismiss Martha’s death as anomalous, or to block out the uncomfortable truths on the grounds that I’m a non-medic and “compromised” by the life shattering consequences of what happened. But they haven’t. They understand the significance of Martha’s story, and they are listening.

It also means so much because I was not listened to while at Martha’s bedside. I raised concerns but was ignored. I was “reassured” but not told the full truth. My opinion about Martha, whose trajectory I was following closely, was never sought by any doctor, junior or senior. I have described in the Guardian the dismissive attitude of consultants on the ward to colleagues in the paediatric intensive care unit; the daily rotating senior doctors who left no notes, so Martha’s trends went unrecognised; how consultants were absent at weekends. What’s crucial is that all these factors meant that failing to listen to me was not only cavalier, it was fatal.

Most wards have effective communication pathways, and the aim of Martha’s rule isn’t to bypass them, but to provide a means of action for those unusual times when deteriorating patients or their families feel their concerns are not being heard—as in the recent case of Maddy Lawrence.4

Such escalation systems, as clinicians who operate Call 4 Concern testify, tend to be used sparingly and can lead to necessary escalations. They aren’t burdensome, aren’t misused, improve communication, and don’t result in poorer care for other patients. Existing outreach teams are often involved. Initial resistance and anxiety on the part of clinicians has been overcome, with the systems soon recognised as a vital safety net.5 To argue, or merely assume, that Martha’s rule will be misused, when the evidence points in the other direction, is just another way of patronising patients.

The importance of the patient voice has been recognised in the medical world for decades. In parallel, cultural problems within medicine—hierarchy, the need for control, the unquestioned assumption that “doctor knows best”—are all too familiar. No one is suggesting that Martha’s rule will instantly solve these difficulties or guarantee that all patients are listened to attentively. But it will shift the balance of power a little on wards, and lives will be saved.

I’m grateful to Henrietta Hughes, the patient safety commissioner for England, for taking on the responsibility of introducing Martha’s rule. A consistent national approach is required, and there are implementation wrinkles to be ironed out. But I trust doctors to understand its merits and embrace it in everybody’s interests. Most of all, I’m relieved that, if a patient or family member finds themselves in the desperate situation I was in, they will now have somewhere to turn. They will be able to activate Martha’s rule.


  • Provenance: not commissioned, not externally peer reviewed.

  • Conflict of interest: Martha’s mother