About Martha’s Rule

The 3 components of Martha’s Rule are as follows:

1. 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.
2. 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.
3. This escalation route will also always be available to patients themselves, their families and carers and advertised across the hospital.

Martha’s Rule will help improve both the quality and safety of care for patients whose condition is worsening. Better identification and management of deterioration is one of NHS England’s key priorities in improving patient safety.

The initiative will empower patients, families, carers and staff to ensure that their concerns are listened to and acted upon. It will also empower staff to have the ability to raise concerns outside of official escalation channels, and to ask for additional support if it’s required.

Implementing Martha’s Rule in the NHS

In May 2024 NHS England announced the implementation of Martha’s Rule across 143 pilot sites across the country, with plans to expand to all providers, including community and mental health, in the coming years, as appropriate and subject to government funding. This is part of a wider programme of work to improve the management of deterioration, incorporating work to improve prevention, identification, escalation and response to acute deterioration.

Martha Mills died in 2021 after developing sepsis in hospital, where she had been admitted with a pancreatic injury after falling off her bike. 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.

In response to this, and other cases related to the management of deterioration, the then Secretary of State for Health and Social Care and NHS England committed to implement ‘Martha’s Rule’ – a patient safety initiative as part of a wider NHS strategy to ensure the vitally important concerns of the patient and those who know the patient best are listened to and acted upon.

Phase 1 of Martha’s Rule 

Following an expression of interest process, phase 1 of Martha’s Rule is being piloted across 143 sites. 3 paediatric critical care operational delivery networks are also testing delivery models for Martha’s Rule. During the pilot year (April 2024 to March 2025), sites will test and implement the 3 components of Martha’s Rule, identifying models that could be scaled up across the remaining providers. The pilot year will also test branding and messaging through planned market research and engagement with pilot sites and wider stakeholders.

To support sites with implementation, a national webinar series is underway which provides an opportunity to share best practice and learn from the worry and concern improvement collaboratives. The patient safety collaboratives, that sit within the health innovation networks (HIN), are providing implementation and improvement expertise through delivery of quality improvement methodology and facilitating communities of practice.

Learning from the pilot sites will inform the development of wider national policy proposals for Martha’s Rule. We are working with providers who are interested in testing in other settings. The intention is to expand to all providers, including community and mental health, in the coming years, as appropriate and subject to government funding.

The National Patient Safety team will lead implementation, in partnership with the National Nursing directorate. Working collaboratively with colleagues from across NHS England, the Care Quality Commission, professional regulators, Royal Colleges, the Healthcare Race Observatory, and the Patient Safety Commissioner, we will provide professional leadership, advice, guidance and support to the pilot sites. We will also draw on learnings from the National Worry and Concern Collaborative. 

How will Martha’s Rule be measured?

During phase 1 we’re keen to understand what areas of implementation are working well and what areas could be improved ahead of any wider rollout. Each pilot site will receive a measurement plan asking them to collect and submit local data which will provide a national view of implementation and enable understanding of impact and learning.

Alongside these quantitative data, the patient safety collaboratives will support pilot sites to collect the qualitative impact of Martha’s Rule implementation: patient and staff experience stories of how this change in practice has made a difference to their care and caring experience.

Other measures to improve the identification of deterioration

The introduction of Martha’s Rule comes alongside other measures to improve the identification of deterioration, including the rollout last November of a new early warning system for staff treating children, built on similar systems already in place for adult, newborn, and maternity services.

To ensure that Martha’s Rule is effective, it will be implemented alongside an integrated programme to improve the management of deterioration using ‘PIER’ resources, which helps systems to prevent, identify, escalate and respond to physical deterioration. This work will improve how the NHS supports staff to manage the prevention of, and deterioration more effectively, as well as encourage greater involvement from patients, families, and carers.

Martha’s Rule builds on the evaluation of NHS England’s Worry and Concern Improvement Collaborative which involved 7 regional pilots and started in 2023. This collaborative tested and implemented methods for patients, families and carers to escalate their concerns about deterioration and to input their views about their illness into the health record.