Careful implementation and evaluation are essential
The death of 13 year old Martha Mills in 2021 from sepsis complicating pancreatic trauma has prompted a call for “Martha’s rule,” to formalise patients’ rights to seek a second opinion. In Martha’s case, the coroner concluded that if she been referred sooner for a critical care opinion she would probably have survived.1 Although people’s initial thoughts would be for Martha, her family, and their loss, many of us were probably soon thinking, “Oh no, not again.”
Sadly, patients coming to harm in healthcare settings is not new. It is 25 years since Cyril Chantler observed that, “Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous.”2 In 1999, the US Institute of Medicine report To Err is Human described between 44 000 and 98 000 deaths occurring each year as a result of medical error in the US.3 Healthcare professionals have accepted the challenge