What is Martha's Rule?

Martha's Rule is an NHS patient safety initiative designed to ensure that concerns about a patient’s deterioration are listened to and acted on quickly. It gives patients, families, carers and staff a clearer route to request an urgent review by a different clinical team when they believe a hospital inpatient’s condition is worsening and the current response is insufficient.

The issue Martha's Rule addresses is not only clinical deterioration. It is also about communication, escalation, a culture of listening, the patient voice, and governance. In serious cases, people closest to the patient may notice changes before formal systems recognise the situation's seriousness. If those concerns are not heard, delay can become dangerous.

In this blog, Dr Richard Dune explains what Martha's Rule is, why it was introduced, how it is being implemented across England, what the current NHS requirements mean, and what health and care providers should do in practice to strengthen patient safety, escalation, communication and governance. The original article correctly frames Martha's Rule as a patient safety change linked to deterioration, listening, escalation and organisational culture.

What is Martha’s Rule?

Martha's Rule is a structured escalation process that supports the early detection of deterioration by ensuring that concerns raised by patients, families, carers and staff are heard and acted upon. NHS England describes Martha’s Rule as a patient safety initiative focused on the early detection of deterioration by ensuring concerns are heard and acted on.

In practice, Martha's Rule allows a patient, family member, carer, or member of staff to request a rapid review by a different clinical team when there is concern that a hospital inpatient is deteriorating and that the current response has not addressed those concerns.

It is important to be clear about what Martha’s Rule is not. It is not a general complaints system. It is not a way to bypass normal ward communication for routine concerns. It is not a replacement for emergency response systems. It is a focused safety route for situations in which deterioration is suspected, and concerns are not being addressed appropriately.

Each hospital has its own local Martha's Rule route. There is no single national telephone number for the public to use. Patients and families are usually directed to local trust websites, ward posters, patient information materials or staff for details of how to access the service.

Why is it called Martha’s Rule?

Martha's Rule is named after Martha Mills, who died in 2021 after developing sepsis following a pancreatic injury. Her parents, Merope Mills and Paul Laity, campaigned for a clearer route to trigger an urgent independent review when patients and families believed a patient was deteriorating and their concerns were not being adequately addressed.

That context matters. Martha’s Rule is not just a procedural change. It is a response to a serious failure in listening, escalation and clinical responsiveness. It challenges organisations to take patients' and families' concerns seriously, especially when those closest to the patient believe something is wrong.

The Care Quality Commission (CQC), General Medical Council (GMC) and Nursing and Midwifery Council (NMC) issued a joint statement saying Martha's Rule reinforces the importance of listening to people who use health and care services and their families, and acting on what they say.

Why does Martha’s Rule matter for patient safety?

Martha's Rule matters because deterioration can be missed, underestimated or escalated too slowly. In hospital care, subtle changes may signal serious deterioration. Families and carers often know the patient well and may notice changes in behaviour, alertness, breathing, pain, colour, confusion or general condition that are not yet fully recognised by staff.

It also matters because healthcare systems can unintentionally create barriers to challenge. Patients may feel unable to question clinicians. Families may worry about being seen as difficult. Junior staff may hesitate to escalate concerns when they feel their judgment is not being heard. Martha’s Rule creates a more explicit escalation route.

Early data show the practical importance of the initiative. NHS England reported that, between September 2024 and January 2026, Martha's Rule calls had led to changes in treatment, including changes to medical, surgical or nursing management such as investigations, diagnostics, medicines, oxygen or intravenous fluids. NHS England also reported that staff made 1,781 calls to Martha’s Rule helplines between September 2024 and February 2026, of which 1,080 helped identify acute deterioration.

That does not mean every Martha’s Rule call identifies serious deterioration. Some calls may lead to reassurance, better communication or improved coordination. But the data shows that Martha's Rule can surface important concerns and support earlier intervention.

How is Martha’s Rule being implemented in England?

Martha's Rule began as a phased NHS implementation programme. It was introduced in May 2024 at 143 phase 1 pilot sites across NHS acute trusts in England. Phase 2 began in April 2025, expanding implementation to the remaining adult and paediatric acute inpatient sites.

NHS England states that Martha’s Rule is being introduced in inpatient services, with an ambition to extend it to maternity, neonatal and emergency departments. It also states that hospitals remain at different stages of implementation, and in some places, Martha’s Rule may currently operate only in specific wards or departments.

The direction of travel is now clear. Martha's Rule is moving from a pilot and expansion programme into a core expectation for NHS trusts and foundation trusts. It is also being tested beyond adult and paediatric acute inpatient services, including selected maternity, neonatal, emergency department, community hospital and mental health settings.

What are the core requirements providers should understand?

Martha's Rule has now been included in the NHS Standard Contract. NHS England’s Martha’s Rule core standards, published on 2 March 2026, state that Service Condition 33 of the NHS Standard Contract 2026/27 requires all NHS trusts and NHS foundation trusts to implement the three core components of Martha's Rule by 31 March 2027.

NHS England's core standards set out what NHS providers should have in place for safe, effective and reliable implementation of Martha’s Rule. The core standards are intended to help organisations move beyond ad hoc local design and towards a more consistent national approach.

For providers, the practical message is that Martha's Rule requires more than a helpline or poster. It needs a reliable operating model, including:

• A clear route for patients and families to request a rapid review

• A mechanism for staff to escalate concerns when they are not being acted on

• A response process involving an appropriate reviewing team

• Communication materials that are visible and understandable

• Governance oversight, monitoring and learning

• Staff awareness and training are linked to local escalation pathways.

This is why Martha’s Rule should be seen as a patient safety and governance system, not simply a communication campaign.

What should providers do in practice?

Providers should implement Martha's Rule in a way that is reliable, visible and embedded in everyday practice.

Establish a clear escalation route

Patients, families and carers need to know when and how to use Martha’s Rule. The route should be easy to find, easy to understand and available in formats that reflect local communication needs.

A process hidden in a policy folder is not enough. Information should be visible on wards, explained by staff and supported through accessible communication. Providers should consider how people with learning disabilities, dementia, sensory impairment, language barriers or low health literacy will understand and use the process.

Build it into deterioration pathways

Martha's Rule should sit alongside existing early warning systems, escalation procedures, outreach arrangements and rapid response processes. It should not operate as a disconnected add-on.

NHS England links Martha’s Rule to wider deterioration improvement work, including preventing, identifying, escalating and responding to deterioration. That means the route should be part of the clinical safety system, not an isolated helpline.

Train staff to respond constructively

Staff need to understand that Martha's Rule is not a criticism of professional judgement. It is a structured safety mechanism. Staff should know how to respond to requests, reassure people, document concerns, and escalate appropriately.

This requires communication skills as well as clinical awareness. A technically sound escalation route can still fail if staff respond defensively, dismissively or inconsistently.

Strengthen the listening culture

Martha’s Rule will not work well where families are viewed as difficult, where staff feel unable to speak up, or where escalation is met with defensiveness. Providers need to reinforce the principle that concerns are information, not interference.

This connects directly with wider good governance in health and social care, as well as clinical governance.

Monitor use and outcomes

Providers should track calls, themes, response times, outcomes, staff concerns, patient and family feedback, and learning from cases. NHS England is collecting data and case studies nationally, and providers should mirror that discipline locally.

Data should not be collected only for reporting. It should help leaders understand whether people are aware of the route, whether staff respond well, whether deterioration is identified earlier, and whether communication improves.

What are the training and competence implications?

Martha's Rule is not a standalone mandatory training topic, as with fire safety or infection prevention and control. However, it has clear implications for training, competence and leadership.

Staff need to understand:

• What Martha's Rule is

• When patients, families, carers or staff may use it

• How the local escalation route works

• How to respond respectfully when concerns are raised

• How to identify deterioration

• How to document and hand over concerns

• How to escalate when they believe a patient is deteriorating

• How Martha’s Rule links to local patient safety systems.

This learning should sit within broader education on deterioration, escalation, human factors, communication, safeguarding, duty of candour, clinical risk and governance.

Providers strengthening workforce capability can use relevant health and social care training resources, leadership and management development, and CPD-accredited online courses. The Mandatory Training Group is also listed with The CPD Certification Service, supporting confidence in its CPD-certified learning provision.

What does Martha's Rule mean for governance?

Martha's Rule is a governance issue because it tests whether an organisation listens, escalates, responds and learns. A provider may introduce a process, but leaders must know whether that process is working.

Governance should include:

• Oversight of Martha’s Rule calls and themes

• Review of response times and outcomes

• Analysis of avoidable delays

• Links to incident reporting and patient safety reviews

• Learning from communication breakdowns

• Ward-level feedback and staff learning

• Assurance that information is visible to patients and families

• Review of equality, access and communication barriers.

For providers using digital assurance systems, ComplyPlus™ CQC compliance system can support evidence organisation, governance oversight and quality improvement workflows.

What are the common implementation mistakes?

Clear implementation helps organisations avoid confusion, strengthen escalation routes and turn Martha's Rule into a practical safety process.

Treating Martha's Rule as a poster campaign

Posters and leaflets are useful, but they do not prove implementation. The process must be understood, staffed, monitored and reviewed.

Confusing it with complaints

Martha’s Rule addresses an urgent concern: a patient's condition is worsening. It is not a general complaints process, although learning from Martha’s Rule cases may inform complaints, incidents and quality improvement.

Making the route hard to access

If the contact route is unclear, difficult to find, not explained to patients or inaccessible to people with communication needs, the system may fail the people it is designed to help.

Treating family concern defensively

Patients and relatives should not have to fight to be heard. Defensive responses weaken trust and can delay escalation.

Failing to support staff escalation

Martha's Rule also supports staff who are concerned that appropriate action is not being taken. NHS England data on staff calls show that staff use of the route can help identify acute deterioration, demonstrating that Martha’s Rule is not only a patient and family route but also a safety mechanism for professionals whose concerns need to be heard.

Not reviewing outcomes

If calls are not reviewed for themes, delays, communication issues or learning, the organisation loses the opportunity to improve. Martha's Rule should generate learning for wards, clinical teams, outreach services and governance groups.

How does Martha’s Rule link to wider regulation and safety?

Martha's Rule should not be understood in isolation. It sits within broader expectations around patient safety, person-centred care, governance, escalation and responsiveness.

It links to:

• Recognising and responding to deterioration

• Listening to patients and families

• Clinical escalation pathways

• Human factors and communication

• Safeguarding and rights

• Duty of candour

• Incident learning

• Quality improvement

• Regulatory evidence and assurance.

For a wider context, readers may also find MTG's guide to key health and social care legislation and regulations, and to the role of the Care Quality Commission, useful.

FAQs about Martha's Rule

Below are some of the most frequently asked questions and answers regarding Martha's Rule.

Is Martha’s Rule available in every NHS hospital?

NHS England says all acute trusts in England are working to implement Martha's Rule, but hospitals may be at different stages locally. Full implementation across acute trust inpatient services is expected during 2026/27.

Who can use Martha’s Rule?

Patients, families, carers and staff can use Martha's Rule where there are concerns that a hospital inpatient is deteriorating and those concerns are not being adequately addressed.

Is Martha’s Rule only for adults?

No. Martha's Rule is being implemented across adult and paediatric acute inpatient services. NHS England is also testing it in selected maternity, neonatal, emergency, community hospital and mental health settings.

Is Martha’s Rule a second opinion service?

No. Martha's Rule is not a general second opinion service. It is a rapid review route for cases with concerns about deterioration and inadequate response.

Is Martha’s Rule the same as making a complaint?

No. A complaint is usually a formal process about dissatisfaction or a poor experience. Martha's Rule is for urgent escalation where there is concern about a patient's worsening condition.

Does Martha’s Rule replace speaking to ward staff?

No. Patients and families should normally raise concerns with ward staff first, where possible. Martha's Rule is used where concerns remain or are not being acted on.

Can NHS staff use Martha’s Rule?

Yes. Staff can use Martha's Rule when they are worried that a patient is deteriorating and appropriate action is not being taken. NHS England has reported staff use of Martha’s Rule helplines to trigger a rapid review of care.

What can happen after a Martha’s Rule call?

A call may lead to a review, changes to treatment, escalation to specialist teams, transfer to higher levels of care, improved communication, or reassurance when the current plan is appropriate.

Is Martha's Rule now contractual?

Yes. NHS England’s core standards state that the NHS Standard Contract 2026/27 requires NHS trusts and NHS foundation trusts to implement the three core components by 31 March 2027.

Why does Martha's Rule matter for leadership?

It matters because leadership determines whether escalation routes are visible, whether staff feel safe to act, whether patients are heard, and whether learning from deterioration concerns improves systems.

Martha’s Rule: Key themes, provider actions and outcomes

Conclusion

Martha's Rule is not only a response to one tragic case. It is a practical patient safety mechanism designed to improve how deterioration concerns are heard, escalated and acted upon in hospital care. Its significance lies in both process and culture.

As implementation continues across England during 2026/27, providers need to show that Martha’s Rule is visible, understood, usable and embedded in patient safety systems. The strongest organisations will treat it not as a helpline alone, but as part of a wider commitment to listening, escalation, clinical governance and safer care.

Strengthen patient safety, governance and workforce readiness

The Mandatory Training Group supports health and social care organisations with training and governance resources to strengthen patient safety, communication, escalation, and workforce capability. If your organisation is reviewing this area, explore CPD-accredited online courses, browse health and social care training resources, or contact our team to discuss your needs.