Blog – Martha’s Rule , what we know so far and how does it affect those working within paediatric critical care?

Martha’s Rule , what we know so far and how does it affect those working within paediatric critical care?

The tragic death of thirteen-year-old Martha Mills in the UK has driven her parents Paul Laity and Merope Mills to advocate for a systematic change in how second opinions are sought by families in emergency situations.

Martha developed sepsis following a pancreatic injury sustained from a cycling accident. Despite her parents’ concerns and the need for urgent care, she was not referred for a critical care review in time, delaying management. Martha’s parents both wrote of their harrowing experiences in the Guardian, the accounts making for a very sobering read. The review into the events leading up to Martha’s demise echoes experiences that most of us have come across in our careers within paediatric critical care: a delay in appropriate escalation due to an overtly hierarchical structure.

Martha’s story highlights multiple broader issues that are encountered, arguably at increasing frequency in the NHS, in part due to ever-growing pressures on the service. Microaggression, miscommunication, incivility and not addressing concerns in a satisfactory manner are all themes that emerged from the review. Martha’s family has proposed “Martha’s Rule,” a Patient Activated Rapid Response service, endorsed (in theory at least) by the UK government. The right to a second opinion of course already exists but the proposed legislation change will specifically apply to emergencies where there is a perceived rapid deterioration of the patient. The idea is for the formation of a dedicated phone service that will allow patients and carers to voice concerns and request an urgent clinical review.

Similar setups have been in place in other healthcare systems.  In Australia, Ryan’s Law has been operational for over a decade. There is yet to be a detailed analysis as to how the review teams will be formed, costed and whether they will be hospital specific or cover a whole region. As such, it is yet unclear on how Martha’s Rule will impact Paediatric Critical Care Services. The RCPCH president has recently suggested that there may be a role for the Paediatric Critical Care Retrieval Services within the new proposals. Whilst we agree that Martha’s rule will be a welcome and important addition to patient safety initiatives, PCCS and its membership remain integral to national level discussions and any subsequent decisions surrounding implementation .The issue at hand relates to timely review of children and escalation to critical care. Our society’s members not only have vital experience in that regard, but are in a position to appraise how any proposed solution might (or might not) work and how it should be costed. Any proposed solution that involves escalation to the PICU will need to be deemed effective and workable by our membership and we will take the necessary steps to ensure that.

Equally, paediatric critical care staff can only be part of the solution. Hospitals need to have their own strategies of escalating concerns and getting urgent senior review at the bedside, after all, bedside examination is and will forever be superior to a remote consultation when done by an experienced clinician. Fundamentally, this tragic case showcased a culture problem within the specific organisation rather than  manifest systems failure. Martha’s rule can be seen as a welcome wedge to hinder similar catastrophes that result from overtly hierarchical structures, but it is only a temporising measure. What would be more effective (albeit harder) however, would be to address those cultural challenges that hinder patient safety instead.

This clearly is a very hot topic both for our membership and nationally. We are delighted to be able to share with you that Martha’s parents have agreed to give a keynote speech at the forthcoming PCCS conference in Liverpool in October 2024. They will be able to share their experience and vision of Martha’s rule in person.

The website is now live ( and we are looking forward to see you all there.

Dr Constantinos Kanaris

PCCS Communications lead

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