Martha’s Rule is a patient safety initiative supporting the early detection of deterioration by ensuring the concerns of hospital in-patients, families, carers and staff are listened to and acted upon.
Recognising that those who know the patient best may be the first to notice changes that could be an early sign of deterioration, Martha’s Rule empowers patients, carers and staff to voice their concerns and request an independent review if they are worried that a patient’s condition is getting worse, and their concerns are not being responded to.
Martha’s Rule was developed in response to the death of Martha Mills who died in 2021 after developing sepsis in hospital. 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.
Martha’s Rule is being implemented in both adult and children’s acute inpatient settings in England. As of June 2026, the initiative is also being rolled out into maternity and neonatal services, and emergency departments nationwide.
– Patient wellness questionnaire: patients 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.
– Staff escalation for review: all staff will be able, at any time, to ask for a review from a different team if they are concerned that a patient is deteriorating, and they are not being responded to.
– Patient escalation: this escalation route will also always be available to patients themselves, their families and carers and advertised across the hospital.
Since May 2024 Health Innovation East and NHS England East of England have collaborated with hospitals across the region to successfully rollout Martha’s Rule.
The programme is bringing organisations together to improve patient safety – strengthening the early identification of, and response to, patient deterioration. The combination of regional leadership and local implementation support has seen the East of England become an important area for learning and spreading good practice for Martha’s Rule.
During 2025-26 our focus moved from rolling out the programme to embedding Martha’s Rule. 18 of 18 NHS sites in the East of England are now testing and implementing the Martha’s Rule programme into day-to-day practice across inpatient adult and paediatric settings.
Our work has included supporting staff to raise awareness of the programme, engaging teams across wards and departments and building understanding of the programme at every organisational level so that Martha’s Rule is visible, accessible and meaningful in clinical environments.
NHS teams around the region have been developing local approaches to collecting and using data to support improvement, share learning and celebrate progress – as these local instances evidence.
Capturing and understanding learning from examples of Martha’s Rule being called into action is essential for sustaining awareness, adoption and to continually improve patient outcomes. 13 detailed case studies from across the region have been shared nationally with NHS colleagues, offering practical insight into how the three components of Martha’s Rule are being used in real settings. Below are just two examples of how the components of Martha’s Rule have shaped learning and improvement.
The patient: In the case of a 69 year old female patient Martha’s Rule provided a pathway for her relatives to secure an independent review, via the hospital’s Martha’s Rule outreach team. The patients relatives said
“We could see mum was deteriorating and we were very much concerned. We would leave our mum every day, worried what we would walk into the next. That’s when we called the Martha’s Rule line. Immediately someone checked on mum, gave us updates and spoke to the doctor on our behalf.
“When we called we were listened to… knowing our concerns were being listened to made such a difference… it felt like mum was on the hospital radar and that she would now be looked after.”
Conclusions drawn: feedback from the patients relatives emphasised;
Action taken: as a result of learning from this case study and the wider adoption of Martha’s Rule, the hospital has
The patient: A 23 year-old patient requiring assistance with day to day care – due to learning difficulties, developmental delay and being non-verbal. In the case of this patient a learning disability nurse, a member of the hospital’s learning disability team raised a concern.
“My professional concerns were based on the patient’s family knowing best, and that the patient was not her usual self.
“The staff nurse and I were aware that escalating under Martha’s Rule felt like undermining a medical professional’s opinion. However, so that the patient remained at the centre and in light that she wasn’t improving, we made a referral under Martha’s Rule for an urgent clinical review.
Once the team were involved it reassured us that we made the correct decision.”
Conclusions drawn: from reflection and feedback
Action taken: as a result of learning from this case study and the wider adoption of Martha’s Rule, the hospital has
All NHS sites across the region chose to implement the core components of Martha’s rule, accompanied by the support of NHS England ODN Critical Care Network and Health Innovation East. The statistics below indicate the significant strides that have been taken.
Across NHS England in the same period, a total of 12,301 calls were received. Of these 33% related to acute deterioration; among this group, 13% required transfers of care to intensive care unit (ICU) or High Dependency Unit (HDU), enhanced levels of care, a tertiary (specialist) centre, or referral or transfer to specialist services or wards. A further 44% resulted in other changes to treatment.
Our commitment to supporting the implementation of Martha’s Rule reflects a shared ambition to improve patient safety, strengthen communication and ensure that the voices of patients, families and carers remain central to care. Together, we also recognise the importance of tackling health inequalities by supporting a broader, system-wide approach to recognising and responding to deterioration.
Caroline Angel, Director of Programmes and Quality Improvement - Health Innovation East
These data demonstrate the scale and clinical impact of Martha’s Rule activations across NHS England – to help bring these positives to light recently Health Innovation East captured the stories of two patients (and their families) The following two stories illustrate how escalations enabled timely changes in care.
Click here to discover Martha’s Rule in action – Elaine and Diane’s story
Click here to know more about the experience of Daniel and his mum.
Our work and the momentum created will continue – accompanied by a sustained commitment to collaboration that results in establishing Martha’s Rule and its components in further care settings – including in Emergency Departments, across maternity and neonatal units.
Looking ahead, we are pleased to continue working together with hospital trusts and Health Innovation East to support sustainable adoption, ongoing evaluation and future spread of Martha’s Rule into additional care settings.
Dr Edward Morris CBE, Regional Medical Director, East of England, NHS England
As the programme progresses we recognise the importance of, and will act to ensure that it makes a positive contribution to, tackling health inequalities in the region.
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