1 Background

Martha’s Rule is a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon.

It has been developed in response to the death of Martha Mills and other cases related to the management of deterioration. Central to Martha’s Rule is the right for patients, families and carers to request a rapid review if they are worried that their or their loved one’s condition is getting worse and their concerns are not being responded to. The three core components of Martha’s Rule are:

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 can work alongside existing physiological scoring systems to increase the sensitivity of identifying and responding to acute deterioration.

Further information about Martha’s Rule and its implementation can be found here.

This report provides analysis of submissions to the Martha’s Rule Data Collection from September 2024 to September 2025. This data relates to phase 1 and phase 2 sites within NHS acute trusts across England. Phase 2 sites began reporting data from August 2025.

2 Response rate

Table 1: Number of valid submissions each month and response rate. The number of valid submissions excludes the submissions that had to be removed due to data quality issues (see Data quality notes). The number of sites changed in July 2025 because one organisation moved from reporting once across two sites to reporting once for each site. The number of sites changed in August 2025 because phase 2 sites began reporting.

Figure 1: Response rate per month. Reporting period from September 2024 to September 2025.

3 Summary

The key figures for the Martha’s Rule Programme data across NHS England from September 2024 to September 2025 are:

• In total, 7,257 Martha’s Rule escalation calls have been received.
• The highest percentage of calls came via the family/carer escalation process (72%).
• 2,723 (38%) Martha’s Rule escalation calls related to acute deterioration.
• 339 calls (5% of acute deterioration calls) required transfers of care to ICU/HDU, enhanced levels of care, tertiary centre or referral/transfer to specialists or a specialist ward.
• 1,029 (14% of acute deterioration calls) required other changes in treatment.

4 Calls analysis

This section examines who made the Martha’s Rule escalation call, calls per region and whether the call related to acute deterioration.

5 Outcomes of Martha’s Rule calls

5.2 Outcome flow analysis

• Of the 7,257 Martha’s Rule escalation calls, 2,723 (38%) related to acute deterioration.
• 339 calls (5% of acute deterioration calls) required transfers of care to adult and paediatric ICU/HDU, enhanced levels of care, tertiary centre or referral/transfer to specialists or a specialist ward.
• 1,029 (14% of acute deterioration calls) required other changes in treatment.

Figure 5: Flow of escalation calls from initial contact through to outcomes. Reporting period from September 2024 to September 2025. Note that from June 2025, up to three outcomes were collected for each acute deterioration call. Only the primary outcome has been visualised here.

Table 5a: Table of outcomes for acute deterioration calls. Reporting period from September 2024 to September 2025.

Outcome	Number of calls	Percentage of the acute deterioration calls
Documented advice (no intervention)	1,355	50%
Transfers of care	339	12%
Other change in treatment	1,029	38%
Total	2,723	–

 

Table 5b: Table of outcomes for calls not related to acute deterioration. Reporting period from September 2024 to September 2025.

Outcome	Number of calls	Percentage of the not acute deterioration calls
Clinical concern	1,481	33%
Communication issue	1,673	37%
Non-clinical concern	541	12%
Signpost to another service/team	523	12%
Other	316	7%
Total	4,534	–

 

6 Interactions with other escalation tools

Of the 512 acute deterioration calls where the patient wellness question was implemented and asked, 106 (21%) were as a direct result of asking the patient wellness question. The outcomes of these calls are shown here.

Figure 6: Sankey diagram showing outcomes for when the Patient Wellness Questionnaire was and was not the reason for escalation. Reporting period from June 2025, when call level data began being collected, to September 2025.

Table 6: Table showing outcomes for when the Patient Wellness Questionnaire was and was not the reason for escalation. Reporting period from June 2025, when call level data began being collected, to September 2025.

Of the 694 acute deterioration calls where an early warning score was recorded prior to the Martha’s Rule call, 573 (83%) would not have triggered a review via standard escalation processes. The outcomes of these calls are shown here.

Figure 7: Sankey diagram showing outcomes for when the early warning score recorded to prior the Martha’s Rule call would and would not have triggered a review via standard escalation processes. Reporting period from June 2025, when call level data began being collected, to September 2025.

Table 7: Table showing outcomes for when the early warning score recorded to prior the Martha’s Rule call would and would not have triggered a review via standard escalation processes. Reporting period from June 2025, when call level data began being collected, to September 2025.

Of the 683 acute deterioration calls where an early warning score was recorded at the time of the Martha’s Rule review, 535 (78%) would not have triggered a review via standard escalation processes. The outcomes of these calls are shown here.

Figure 8: Sankey diagram showing outcomes for when the early warning score recorded at the time of the Martha’s Rule call would and would not have triggered a review via standard escalation processes. Reporting period from June 2025, when call level data began being collected, to September 2025.

Table 8: Table showing outcomes for when the early warning score recorded at the time of the Martha’s Rule call would and would not have triggered a review via standard escalation processes. Reporting period from June 2025, when call level data began being collected, to September 2025.

7 Children and young people

This section specifically focuses on acute deterioration calls related to children and young people (0-18 years old).

Table 9: Calls relating to deterioration in children and young people. Note: Age boundaries changed in the November 2024 data collection template so this only shows data from November 2024 to September 2025.

8 Data quality notes

• This data collection is not mandatory. Therefore, different sites may submit information each month.
• The national data relates to calls made and thus one patient may have used Martha’s rule escalation multiple times.
• This data is true as of the time it was extracted, some of these figures may change subject to sites re-submitting.
• Where data quality issues were identified, these submissions were removed. This impacted 4 different sites over 5 different months (5 submissions in total).

9 Glossary

Table 10: Glossary of terms.

10 Additional information

The Martha’s Rule Programme is led by the National Director of Patient Safety in NHS England. The implementation is being led and facilitated by the National Patient Safety team in partnership with the National Nursing Directorate.

Data source: the Martha’s Rule Data Collection.

11 Future publications

Your feedback is welcome on the format, frequency and utility of this document, so that we can provide reports that are of most benefit. Please contact patientsafety.analysis@nhs.net with any suggestions.