Martha Mills died in 2021 of a preventable cause. Doctors now need to make sure this type of tragedy is far less likely to happen again.
But how could it be done? The logistics will be complicated and not easy to administer. Here is one way it could be done. It needs to be thought through slowly and carefully.
Base it on PALS (hospital and outside)
1. MyHSN thinks it would be best to base it on the hospital PALS system: https://www.myhsn.co.uk/top-tip/what-is-a-hospital-pals-team. Why? Its admin structure up and running. And as any hospital doctor will know, it works.
2. And we should develop similar PALS teams in GP/community and Mental Health. Also why should dentistry and optometry should be excluded?
4. We think 3 speeds of response will be required (see below) – all of which can be instituted (not requested) easily by the patient, or a designated next of kin (NOK)
5. But NOK is hard to define, and will change, and the patient needs to agree they are their NOK from the age of 18 years onwards. It is currently not mandatory to have or record a NOK, partly as it keeps changing and partly for IT/comms reasons. And what about orphans or migrants? Will they need a separate advocate system?
Three PALS responses
6. ‘PALS1 alert’ – immediate, call the ‘crash team’. That would have to be strengthened by adding a critical care outreach team member (nurses), so they can stay with patient and request the rapid second opinion; as the crash teams need to be freed to go to next call (usually a non-Martha’s crash call etc). But not all hospitals have such an outreach team, and those that do, may not be there 24h a day.
7. ‘PALS2’ – within 12 hours. Suitable for non-life threatening situations on wards (e.g. patient turned down for an operation, or wants one, and doctors don’t etc).
8. ‘PALS3’ – within a week. Suitable for a hospital OP (or GP clinic). Most bad calls happen there, not on a ward.
Presumably a ‘Community Martha PALS system’ will need PALS2 and PALS3 response speeds, not PALS1 – e.g. someone sees an optometrist with rapid onset of unilateral blindness on a Friday and they say ‘go to Eye Causaulty on Monday’. They should go now.
Leadership
9. We would need to develop a rota of seniors (deputy Chief Med Officer level?) in hospitals (where such roles exist) and GP/community and Mental Health (where they do not) to back up PALS; so consultants/GPs asked to deliver a second opinion do so (they will need rota too) at which pace. In other words, 2 rotas will be needed; in fact there will need to be 3 with the PALS teams co-ordinating 24 hours a day, 7 days a week. All may want paying, and perhaps they should be paid.
10. Those second opinion seniors will be unkeen to be forced into second opinions unless they have medico-legal immunity. And there will be huge conflicts of interests, e.g. you are the doc they disagree with and the one on the second opinion rota, or you are a junior consultant and have to challenge the head of department that you need for promotion or an appraisal soon etc. And what happens in a PALS2 response where the second opinion does not feel they know enough to answer the question, or it will take 3 days?
Also we should consider a ‘PALS2-3E’ (external), i.e. to enable the public to call for a second opinion from a similar team in a nearly hospital or GP practice? Groups of doctors often train together and develop ‘group-think’, i.e. all will practice in a similar way and agree on everything.
Should it be UK-wide?
Yes. If its a NHS England thing, why? NHS Scotland, Wales and N Ireland should follow suit, so it is fair to their people. Or should a new act be ‘generic’ and say each nation should have a system made up on these principles but how you do it, at a nation level, is up to you. Do such ‘general principle’ acts work?
Could it be ICB-based in England?
Alternatively NHSE could entrust each ICB in England to construct a system, i.e. be a policy but with no law. But could that lead to 42 very different things none of which work properly – and be part of a postcode lottery.
Summary
This is not going to be easy. And a badly thought out system will lead to chaos. And what about vexatious complainers that constantly activate Martha’s Law?
Nonetheless, it is time for doctors to join with the DHSC and start work on developing a Marthas Law – and more especially make sure it leads to a system that works, and prevents future tragedies like Martha.