Martha’s story

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 clinical deterioration, the then Secretary of State for Health and Social Care and NHS England committed to implement ‘Martha’s Rule’ across the NHS.

What is Martha’s Rule?

Martha’s Rule recognises that those who know the patient best may be the first to notice changes that could be an early sign of deterioration, and the importance of listening to and acting on the concerns of patients, families, and carers. It is being implemented in both adult and children’s inpatient settings in England.

The 3 core components of Martha’s Rule

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

Empowering patients, families, carers and staff

Martha’s Rule actively encourages patients, families and carers to tell staff if they are worried a health condition is getting worse. They may notice small changes that could be early warning signs of deterioration before they show up in routine measurements.

If, after speaking to the care team, they remain worried and feel their concerns are not being addressed, they can call a dedicated number for a rapid review from a different team.

Martha’s Rule also empowers staff to call for a rapid review if they feel their concerns about a patient are not being responded to.

Evidence suggests Martha’s Rule is saving lives

To support learning and assess the impact the programme is having, we regularly collect data from sites where Martha’s Rule is in place.

Early evidence suggests Martha’s Rule is saving lives. Data from September 2024 to June 2025 shows 4,906 Martha’s Rule calls were made, with the highest proportion of calls (71.9%) made via the family escalation process. 2,132 Martha’s Rule escalation calls (43%) related to acute deterioration. Of those, 241 calls resulted in potentially life-saving escalations of care, including:

• 93 urgent admissions to high dependency or intensive care units
• 49 resulting in transfers to another enhanced level of care or to a tertiary centre

Changes in care were also noted for a further 720 calls, for example the introduction of a new medication such as an antibiotic to treat infection, investigations including scans and referral for specialist input. Where calls did not identify deterioration, they are still supporting staff to provide better care and address concerns.

The data highlights the importance of listening to patient and family/carer concerns and how Martha’s Rule can work alongside existing physiological scoring systems to increase the sensitivity of identifying and responding to acute deterioration.

Please note that these data have been published as management information. Data source: the Martha’s Rule Data Collection. Martha’s Rule data will be published monthly from September 2025.

Implementing Martha’s Rule

In May 2024, Martha’s Rule began being introduced at 143 phase 1 pilot sites within NHS acute trusts across England. Following positive results from the first year, phase 2 of the programme commenced in April 2025, expanding Martha’s Rule to all remaining sites that provide adult and/or paediatric acute inpatient services.

As part of phase 2, the programme is also supporting the testing of Martha’s Rule in a small number of maternity and neonatal units, emergency departments, community hospitals and mental health settings.

Monthly data returns and case studies from the Martha’s Rule sites are building a national picture of how Martha’s Rule is being implemented in practice. This is enabling the national Martha’s Rule programme team to assess its impact on patient safety, identify key learning, and support wider adoption.

There has also been a focus on accessibility, ensuring this service is available to everyone and providing hospital staff with the appropriate training to support patients, families and carers to use Martha’s Rule.

Supporting Martha’s Rules sites

The programme is delivered collaboratively with colleagues across NHS England, including the Children and Young People team, critical care networks as well as teams specialising in mental health, community, maternity, neonates and emergency medicine.

Through the programme board we are also working collaboratively with patient safety partners, the Care Quality Commission, professional regulators, Royal Colleges, the Healthcare Race Observatory and the Patient Safety Commissioner.

Martha’s Rule sites receive comprehensive support through the national Martha’s Rule programme team at NHS England and locally through the patient safety collaboratives. This includes implementation guidance, regular learning events, peer support networks, and dedicated resources to help overcome challenges.

Communications, key messages and branding

Independent audience research and testing around messaging, branding and the identity of Martha’s Rule has taken place to support providers to ensure how they communicate about the programme is done in a way that resonates most with patients, families and staff across a diverse range of communities and age groups.

This includes specific messaging and communications materials for adult and children’s healthcare settings.

A national communications toolkit was published in April 2025 on the Department of Health and Social Care’s Campaign Resource Centre which pilot sites are encouraged to use.

How Martha’s Rule fits with wider work to identify and manage deterioration

Better identification and management of deterioration is one of NHS England’s key priorities in improving patient safety. The PIER approach (prevention, identification, escalation and response) views deterioration as a whole pathway and will support effective management of acute physical deterioration.

The introduction of Martha’s Rule comes alongside other measures to improve the identification and response to deteriorating patients in a healthcare environment, including the National Early Warning Score (NEWS) and the new early warning system for staff treating children that was launched in November 2023.

Martha’s Rule builds upon learning from NHS England’s Worry and Concern Improvement Collaborative, which began in 2023 across 7 regional pilot sites. This earlier initiative tested and developed approaches for patients, families and carers to escalate concerns about deterioration and to have their observations about their own or their loved one’s condition formally recorded in health records.