Intended for healthcare professionals


Challenging NHS hierarchy can save patients’ lives—I’ve seen how it saved my son

BMJ 2023; 383 doi: (Published 15 November 2023) Cite this as: BMJ 2023;383:p2687
  1. Zosia Kmietowicz
  1. News editor, The BMJ

NHS hierarchies and paternalistic cultures can mean patients’ and families’ concerns are dismissed or undermined—but challenging them can be lifesaving

At the heart of the many deaths from sepsis are the unheard voices of the families and carers who tried to raise the alarm and had their concerns dismissed or ignored. Hierarchies and medical paternalism are the issue behind the drive for Martha’s rule to be introduced in the NHS.1 Martha Mills died in 2021 aged 13 years from sepsis at King’s College Hospital NHS Foundation Trust in London, and her parents have been instrumental in calling for a legal right to a second medical opinion,1 which the government is now working towards. An experience with my son made me realise that to make care safer, the onus to challenge medical hierarchies must be on clinical staff too, not just parents and carers.

Though progress on reducing deaths from sepsis has been made,2 I was saddened to read about yet another preventable death.3 Four year old Daniel Klosi died from sepsis in April despite repeated visits to an emergency department in London and pleas from his parents for doctors to do something about their son’s worsening condition.3

Cases like Daniel’s are close to home because I have seen how challenging medical hierarchy probably saved my son’s life. After a sleepless Friday night, my son (then 14 years old) said that he felt terrible and had pain in his foot. I thought he had a football injury and perhaps the flu, so I gave him a couple of paracetamol before heading out. When I returned home, my son, who rarely complains, said he was feeling worse. NHS 111 advised me to get him to the emergency department, but, when he couldn’t walk, I called for an ambulance. The paramedic who examined him checked if he was sensitive to light, and I knew he suspected meningitis, but we were both reassured when he didn’t react.

At the hospital I requested stronger painkillers for my son’s pain and asked for someone to look at him urgently. Eventually a doctor arrived, puzzled over the painful foot, and decided an x ray would uncover the cause. But, as he was being wheeled out of the room, the matron of the emergency department took one look at him and raised her hand for everyone to stop where they were. “This child is seriously ill,” she said, before removing my son’s T-shirt to examine him. She pointed at tiny red specks on his shoulders and questioned if the doctor still wanted to order an x ray. The doctor was flustered and started to mumble. Only she had the authority to determine the next step, and, after more prompting from the matron, she requested a consultant opinion and ordered antibiotics for suspected meningitis. Before long, my son was attached to a drip and was being wheeled to the ward.

As we left the emergency department, I squeezed the matron’s shoulder and thanked her for her intervention. She looked at me quizzically as if to say it was nothing, she was just doing her job. Meningococcal meningitis was confirmed a few days later, by which time my son was already on the mend. He made a full recovery with no lasting effects.

I tell this story because, as Martha’s mother, Merope Mills, advises, relatives and carers should challenge the hierarchies in medicine and reject dismissive or paternalistic attitudes. But the onus must also be on healthcare professionals to confront their seniors when they suspect something is not right—no matter where they sit in the perceived hierarchy—to request tests when they think it is appropriate, and not to worry about the consequences or repercussions. Just like the matron did in my son’s case.

Merope Mills blames hospital teams working in silos and the culture which was “dominated by hierarchy, status, and overconfidence” for preventable deaths. She said that many of the highly experienced consultants had “complete disregard” for junior doctors. Hierarchy can be dangerous and inhibiting. There is no escalation system like Martha’s rule for healthcare professionals to challenge another clinician’s proposed care. But challenging the decisions of another clinician—just as matron did on that Saturday when my son was sick—should be possible without the fear of damaging your career, your concerns being dismissed, or ending up feeling humiliated. Being open to different opinions and treating your colleagues with respect should be the foundation of any organisation.


  • Competing interests: None declared.

  • Patient consent: Obtained.

  • Provenance and peer review: Commissioned, not externally peer reviewed.