Jess’s and Martha’s Rules Should Not be Needed
As I mention in my medical memoir, An English Doctor in Japan, sometimes the encounter with patients for no good reason may be referred to as ‘the front line’ or even as ‘the coal face’ of general practice. Worse, in discussions with colleagues during a coffee break, when asking if any interesting patients had been seen, the cynical reply might be, ‘No, only the rubbish.’ This I used to find shocking. Is the patient the enemy? Alas, it seems as if this might be their attitude if some doctors appear to want to do the minimum and dismiss patients’ concerns.
One lesson I learnt early on in my career in general practice is to ‘think again’ if a patient comes twice within a short time for the same problem, especially in the case of a child. You can’t always be certain if you’ve made the right diagnosis the first time, and should always keep an open mind for other possibilities. The NHS seems at last to have woken up to this fact, even though they say this applies if a patient comes three times – an arbitrary number – for the same problem. Does this mean doctors needn’t be worried if a patient only comes twice for the same problem? It’s even been given a name, Jess’s Rule, after campaigning by the family of a patient called Jessica Brady who died in December 2020 aged 27 after contacting her GP practice more than twenty times over a five-month period. Apparently, she was dismissed each time but after a private consultation elsewhere, when it was too late, she was diagnosed with terminal cancer.
Her symptoms were unintentional weight loss, night sweats, chronic fatigue, a persistent cough, and enlarged lymph glands. These features are enormous ‘red flags’ indicating a serious illness. The diagnoses of tuberculosis, lymphoma, and cancer immediately come to mind; there are many other possibilities.
The point I wish to make is that of course this unfortunate patient’s symptoms should have been taken seriously and a proper assessment carried out, if not at the first contact with her GP, then certainly at the second approach.
We shouldn’t need a Jess’s Rule.
A complicating aspect of this case is that it occurred during the Covid epidemic, and many medical consultations were held remotely. But if there is a clear need, then with due precautions a personal meeting with a doctor is mandatory. There is always a risk in medical practice of medical staff acquiring an infectious disease from a patient, but this is a recognised occupational hazard.
We also have another tragic case which gave rise to Martha’s Rule.
According to the NHS, ‘Martha’s Rule is a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon.
‘Martha Mills died in 2021 after developing sepsis in hospital, where she had been admitted with a pancreatic injury after falling off her bicycle. Martha’s family’s concerns about her deteriorating condition were not responded to, and in 2023 a coroner ruled that Martha, aged 13, would probably have survived had she been moved to intensive care earlier.
‘Patients [in hospital] will be asked, at least daily, about how they are feeling, and if they are getting better or worse, and this information will be acted on in a structured way.’
Isn’t this what should be happening routinely? Hospitalized patients by definition have a serious or potentially serious problem and therefore of course they should be under close watch in case their condition is deteriorating. And if this is so, obviously they must promptly be reviewed or referred without delay to a more experienced doctor or medical team.
We shouldn’t need a Martha’s Rule.
Text © Gabriel Symonds
Picture credit: Wikimedia Commons