The tragic death of 13-year-old Martha Mills, following poor and possibly negligent care at a leading London hospital, brought back bitter memories of the death of one of my own patients.
It also confirmed to me why the plan to introduce Martha’s rule, which would give every hospitalized patient the right to a second opinion from other experts at the same hospital, will unfortunately not help.
In February, the Government announced that hospitals in England would be offered funding to implement the rule. 143 have already signed up, as reported today, and they should be operating the plan by 2025.
Martha’s parents have been heroic in their efforts to try to spare others the terrible and unnecessary loss of a loved one.
Martha’s Rule follows the tragic death of 13-year-old Martha Mills, who died after developing sepsis in 2021 under the care of King’s College Hospital NHS Foundation Trust in south London.
But Martha’s Rule, while laudable, I fear cannot accomplish one thing that is vital to its success: changing our hospitality culture.
I don’t just mean that people are afraid to speak out, to challenge the hierarchy of high-level doctors, that’s why is It’s still a problem (although it’s getting better, slowly).
I am referring to the lack of continuity of care (no longer taking full responsibility for a patient throughout their entire hospital “journey”) that occurred when the structure of hospital care changed beginning in the late 1990s.
There is no doubt that, when in doubt, questioning the doctor is a totally acceptable and justified attitude. And it can save lives.
I have never forgiven myself for not intervening more aggressively on behalf of one of my patients, knowing in retrospect that if I had, he would have survived.
The only way to prevent avoidable deaths in the NHS is to change our hospital culture, writes Dr Martin Scurr
She had gone to the emergency room (as in Martha’s case, to a major London hospital (although different)) on a Friday night with a high temperature, rigors (sweating and chills), and intense pain on one side of her abdomen.
Yes, he was almost 90 years old, with type 2 diabetes and a history of heart surgery, but until the day he became ill with a kidney infection, he had been able to work full time.
Always dressed in a three-piece suit and with the upright bearing of a gentleman, he was the image of how many of us would like to be seen with that vintage: elegant and cognitively intact.
But when I went to the hospital to see him on Monday afternoon after my morning appointments (with a three-day beard, desperately ill with developing sepsis, dehydrated and now slightly confused) he was lying parked on a corner bed, where there was spent the entire weekend taking a small dose of an oral antibiotic: with sepsis he should have received an antibiotic drip.
I was worried about his condition and called the consultant (the ward staff were not helpful, but I found the consultant’s name above the head of the bed).
The consultant told me that as it was almost five in the afternoon, the patient would be handed over to a new team.
That was where he should have intervened, although as his family doctor he had as much authority as any loved one.
What my patient needed was immediate intensive care, but as I suspect many doctors would do, I submitted to the hierarchy: I was treading territory where I had no mandate, waiting instead for the consultant to inform the colleague that he was about to take on the task. control. , about my concern.
But I should have crossed that invisible line.
While those who cared for him in the real world knew this man in his normal, healthy, magnificent state, the hospital team clearly saw him as a pre-terminal geriatric with a urinary tract infection.
He died the next day after receiving minimal care and no one watched him to witness his rapid deterioration.
I took his death very hard. I felt very guilty for not having intervened more successfully.
In my view, a major contribution to this type of tragedy is the fragmentation of care: the lack of continuity under a single hospital team.
This is a result of the loss of the old system where care was provided by a traditional “firm”, a team headed by one or two consultants with senior registrars (just below consultant level), registrars, senior house officers ( two to three years out of medical school) and stay-at-home moms (recently graduated from medical school).
In the old “enterprise” system, responsibility moved up each level of the team: the most junior members cared for the most patients, and when things went wrong, they raised concerns at the next level up; for example, to the registrar, who may well speak to the senior registrar and sometimes the consultant also intervenes.
This might seem like a recipe for “groupthink”, a kind of meaningless consensus of opinion, but my argument would be that recurring auditing and introspection about whether the right actions are being taken counteracts that.
Additionally, it was not uncommon for a consultant or senior registrar to make the decision to ask another team to come take a look, a sort of joint team meeting.
The company’s sense of responsibility meant that senior doctors were often seen turning up at weekends if they were worried about a particular patient.
But in my patient’s case, the old type of “company” had long since disappeared (a victim of the shift of power to management and new restrictions on working hours). It was a weekend so there was probably only one harried junior doctor, no ward visit on Saturdays, probably no one came to see my patient unless maybe one of the nursing team called the doctor on duty for him to come, who maybe there was? Then they shrugged their shoulders and noticed that it was an older person who was leaving…
The old close-knit team (who cared for patients throughout the treatment period and took full responsibility) has evolved into what we have now, with experience and increasing responsibility (and full accountability) lost.
We will never put the genie back in the bottle and no amount of strengthened regulation or Care Quality Commission inspections and sanctions will achieve the diligence of the past.
Nor will a legal framework, Martha’s rule, that imposes the option of a second opinion when requested.
Despite their undoubted good intentions, fueled by such a heartbreaking and unnecessary tragedy, I believe that standard will be a failure: fiddling while Rome burns.
