Purpose

By setting out 6 core standards, this guidance describes what NHS providers should have in place for the safe, effective and reliable implementation of Martha’s Rule.

It helps NHS providers to meet the requirement under Service Condition 33: Patient Safety of the NHS Standard Contract 2026/27: “33.13 The Provider, if it is an NHS Trust or an NHS Foundation Trust, must implement the three core components of Martha’s Rule by 31 March 2027”, as well as support local assessment, commissioner assurance and inspection. The guidance describes the application of each of these components, but does not prescribe operational processes, tools or specific roles or responsibilities to allow adaptation to local context while maintaining the intent of each component.

How to use the Martha’s Rule core standards

• Organisations should review each core standard to assess whether Martha’s Rule is implemented reliably and effectively.
• The standards are designed to enable providers to self-assess and obtain assurance on Martha’s Rule implementation or identify gaps for focused improvement. They can be used for audit to support providers, commissioners or for inspection purposes.
• Each standard includes a self-assessment question to guide discussion and identify areas for improvement.
• Implementation should always consider equity, patient involvement and inclusivity.

Organisations should regularly review their implementation of Martha’s Rule, using the self-reflection questions and local data to identify strengths and areas for improvement, and to ensure that equity, patient involvement and staff confidence remain central.

Core standards

Standard 1: Reliable implementation and equitable access to all components of Martha’s Rule

Intent

 To ensure that all 3 components of Martha’s Rule – patient wellness question, access to escalation and rapid clinical review – are implemented in line with guidance.

• All 3 components are operational and consistently accessible to patients, families, carers and staff in both adult and children’s inpatient settings in England.
• The patient wellness question is asked in line with adult, children and young people implementation guidance to ensure it is always asked in the same way (including response options) and the patient or family member’s direct response is recorded and actioned appropriately.
• Rapid reviews are carried out in line with guidance: reviewers are independent, appropriately skilled and can undertake or facilitate the review.
• Patients, families, carers and staff can reliably activate escalation and access rapid review.

Self-assessment question

Would patients, families, carers and staff be confident that all 3 components of Martha’s Rule are reliably available and implemented as intended?

Standard 2: Rapid review conducted by independent, appropriately skilled clinicians

Intent

To ensure that when Martha’s Rule is activated, a rapid review is conducted or facilitated by an independent clinician with the appropriate skills.

• Rapid reviews are triggered promptly and involve a clinician not directly responsible for the patient’s ongoing care.
• The reviewing clinician has the appropriate skills to assess deterioration and either undertakes the review or facilitates timely access to the right clinician.
• The review focuses on the concerns raised and considers the patient’s condition in the round.
• All concerns raised by patients, families, carers and staff are listened to and acted on appropriately.
• Outcomes and any actions are communicated clearly to those who raised the concern, including patients and families.

Self-assessment question

If Martha’s Rule were activated today, would there be confidence that an independent clinician could review the patient and provide clear feedback to those involved?

Standard 3: Meaningful involvement of patients, families, carers and staff in the patient wellness question and rapid review

Intent

To ensure that patients, families, carers and staff are meaningfully involved in the patient wellness question and the rapid review process, so concerns are accurately captured and acted on.

• Patients and families are made aware of the patient wellness question and understand its purpose and how their responses are used, whether within or outside an early warning system.
• Patients are always involved in the patient wellness question, other than in exceptional circumstances, for example when sedated.
• Older children who can engage are supported to answer the patient wellness question for themselves.
• Families or carers support patients with a learning disability or dementia or who are a very young child to answer the patient wellness question or provide relevant information. A staff member can advocate for such a patient who has no support.
• Where patients cannot engage directly, supportive tools such as soft signs of deterioration, observations or communication aids are used.
• During rapid review, patients, families, carers or staff who raised the concern are actively listened to, and their perspectives and responses are recorded and used to inform decisions about the patient’s care.
• Feedback from both the patient wellness question and rapid review is provided in a way that patients, families, carers and staff can understand and use.
• Staff understand their role in monitoring and escalating deterioration and how the patient wellness question will support their understanding of a patient’s condition over time.

Self-assessment question

Would patients, families, carers and staff report that their perspectives are actively sought, captured and used in both the patient wellness question and rapid review?

Standard 4: Equitable access, awareness and understanding of Martha’s Rule

Intent

To ensure that patients, families, carers and staff are aware of Martha’s Rule and can access it fairly and consistently.

• All relevant groups are aware of Martha’s Rule and understand its purpose and how to access it.
• Martha’s Rule is promoted to all patients, families and carers, to ensure access is equitable across different needs, circumstances and clinical settings.
• Communication aids are readily available to support those whose first language is not English, who have low health literacy or who have a disability that limits access.
• Staff support patients and families to access Martha’s Rule.
• No patient, family member, carer or staff member is disadvantaged by language, disability, role, background, confidence or access to digital devices.

Self-assessment question

Would all relevant groups have equal opportunity to know about and access Martha’s Rule?

Standard 5: Staff education, knowledge and understanding of Martha’s Rule

Intent

To ensure that all staff understand Martha’s Rule and their role in supporting it, have the confidence to recognise deterioration, involve patients, families and carers, and are able to activate and respond to the review process as appropriate.

• All staff understand the purpose and intent of all 3 components, including locum, agency and transient staff.
• Staff have the knowledge and the confidence to recognise changes in wellness and support patient, family and carer involvement.
• Staff know how to facilitate or activate escalation and rapid review.
• Staff understand how to involve patients who cannot self-report directly and older children appropriately.
• Staff feel empowered, supported and able to act when they have a concern or when concerns are raised with them.

Self-assessment question

Would staff feel confident that they understand Martha’s Rule, their role in the patient wellness question and escalation, and how to involve patients, families and carers appropriately?

Standard 6: Embedding Martha’s Rule in governance and quality management systems

Intent

To ensure that Martha’s Rule is integrated into the organisation’s broader approach to patient safety, deteriorating patient management and quality improvement.

• Martha’s Rule is reflected in governance structures, quality management systems and strategies for patient deterioration.
• Martha’s Rule continues to be aligned with other patient safety initiatives around deterioration such as NEWS, NPEWS, NEWTT2 and MEWS.
• Responsibilities for oversight and review are clear.
• Martha’s Rule is embedded as a routine part of patient care, not a separate process.
• Data is submitted nationally and used locally to generate insight and continually improve patient outcomes, experiences and care.
• Feedback and learning from activations of Martha’s Rule is used to inform governance, quality management and staff training.

Self-assessment question

Would organisational leadership and governance structures be able to describe how Martha’s Rule contributes to patient safety and insight generation, and how improvements are identified and acted on?

Publication reference: PRN02279