Listening with intent - Martha's Rule for Wales

Martha’s story starts in Wales. Martha is a teenager on holiday. A cycling accident near Barmouth results in injury to her pancreas. After being seen by doctors in hospitals in Aberystwyth and Cardiff, she is transferred to a tertiary unit in London. A breakdown in communication between teams means that the growing concerns of her parents are not heard. Martha suffers a cardiac arrest and subsequently dies in intensive care.

It's an awful story. But sadly, not uncommon.

Have you ever visited a friend or relative in hospital, heard about how they were being managed and then felt desperately uncomfortable with some aspects of their care? Healthcare professionals in this situation often find ways to contact a senior member of the team or someone they know in the department to discuss and improve care.

Martha’s Rule says that this pathway of raising critical concern should be open to staff, patients and family members alike and, following a campaign by Martha’s parents, the Patient Safety Commissioner for England wrote to the then Health Secretary to recommend ‘a structured approach to obtain information relating to a patient’s condition directly from patients and their families at least on a daily basis’.

This means 24/7 access to a rapid review from a critical care outreach team that staff, patients, families and carers can contact should they have concerns about a patient. This 24/7 rapid review from a critical care outreach team should be advertised around the hospital and more widely so that patients and families know that they can contact the team if they are worried about their condition. This is Martha’s Rule.

Martha’s Rule is now being piloted in over 140 hospitals in England and has been recommended to hospitals in Wales. Ysbyty Gwynedd in Bangor and University Hospital Wales in Cardiff have introduced a ‘call-for-concern’ system, linked to the critical care outreach team.

What surprises most people is that the number of patients and family members who raise concerns through this route is small (1–2 per week) but most often, it is the breakdown of communication between parents and the healthcare team that leads to an issue.

What is the ‘structured approach’ to obtaining information relating to a patient’s condition? The pilot sites in England are using something called the ‘patient wellbeing scale’. In essence it is the question ‘are you feeling better?’ with a graded response. It sounds trivial but is core to everyday routine assessments of patients. Does it matter if people are feeling better? John Kellett and co-workers found in 2017 that ‘acutely ill medical patients who feel their condition has improved on their first re-assessment after admission to hospital’ had a dramatically lower hospital mortality. So, it probably does matter.

We have now undertaken a baseline audit of the ‘patient wellbeing question’ in several hundred patients in Bangor. When interviewed, most patients believe that someone has asked them about their wellbeing in the previous 24 hours. Reassuringly, when we asked them, more than half of the patients reported feeling better than the previous day. But their answer to the question was often not retrievable from nursing or medical records. It is difficult to say whether staff listened to their answer and acted upon it. Martha’s Rule is a patient safety initiative, so recording the answer in patient’s medical records is a critical component to improve safety and care. Martha’s experience would suggest that this could make all the difference.