The introduction of Martha’s Rule marks an important development in patient safety within the NHS. It gives patients, families, carers and staff clearer ways to raise concerns when they believe someone’s condition is worsening and those concerns are not receiving an appropriate response.
Martha’s Rule is a patient safety initiative designed to support the early recognition of deterioration.
It is named after 13-year-old Martha Mills, who died from sepsis in 2021 after her condition deteriorated while she was receiving hospital care. Her parents, Merope Mills and Paul Laity, repeatedly raised concerns about her worsening condition and later campaigned for patients and families to have a clearer way to request an urgent review.
Martha’s Rule is sometimes described as a right to a second opinion, but its purpose is broader. It creates formal routes for patients, families, carers and NHS staff to request a rapid review from a separate clinical team when concerns about deterioration have not been adequately addressed.
The rule has three core components. Patients should be asked at least once a day how they are feeling and whether they believe their condition is getting better or worse. NHS staff should be able to request a review from a different clinical team if they remain concerned about a patient. Patients, families and carers should also be able to request a rapid review when they believe someone’s condition is worsening and their concerns have not been addressed.
The exact process may vary between hospitals, but the concern should be reviewed promptly by an appropriately skilled clinician or team that is separate from the patient’s immediate care team. The outcome should then be clearly communicated to the person who raised the concern. Depending on the findings, this could lead to further assessment, changes to treatment, specialist input or transfer to a higher level of care.
Martha’s Rule was introduced to strengthen the way hospitals recognise and respond to deterioration.
Clinical observations and early warning scores remain important, but patients and those who know them well may notice changes in behaviour, appearance or wellbeing before these are reflected in routine observations. Staff may also remain concerned about a patient after using established escalation processes.
Martha’s Rule provides an additional safety route, helping ensure these concerns can be raised, reviewed and acted upon. It also supports a more open approach to patient safety by giving patients, families, carers and staff a clearer voice when they feel something is wrong.
Martha’s Rule began rolling out across 143 acute hospital sites in 2024 and has since been expanded to every acute hospital in England. NHS Trusts and Foundation Trusts are required to implement all three core components by 31 March 2027.
Successful implementation requires more than providing a telephone number. Hospitals need clear processes for raising concerns, coordinating reviews and communicating outcomes.
Staff need to understand the purpose of Martha’s Rule, when it should be used and what their responsibilities are when a concern is raised. Patients, families and carers also need clear and accessible information explaining how to request a review and what they can expect from the process.
Hospitals must also ensure that appropriately skilled clinicians are available to provide a timely and sufficiently independent review. The process needs to work quickly, particularly where there is concern that a patient’s condition is deteriorating.
Clear communication is central to this. Hospitals should be able to see when an escalation was raised, who received it, whether it was acknowledged and what action followed. Digital communication systems can support this by routing urgent requests, notifying the appropriate team and maintaining a record of the response.
Martha’s Rule strengthens the role of patients, families, carers and staff in recognising deterioration.
For healthcare professionals, it provides an additional patient safety mechanism and encourages a culture in which concerns can be raised openly. It can also bring another clinical perspective into complex or uncertain situations.
Implementation may create operational pressures, particularly where staffing and clinical capacity are already stretched. Clear responsibilities, effective training and reliable communication processes will therefore be essential.
The effectiveness of Martha’s Rule depends on concerns reaching the correct person, being acknowledged and leading to an appropriate response.
Alertive supports role-based, priority-led and auditable communication across healthcare organisations. It can help connect the teams involved in deterioration and escalation pathways, providing greater visibility from the initial concern through to the clinical response.
The design and governance of each Martha’s Rule pathway remains the responsibility of the NHS organisation. Digital communication can support that pathway by helping important information reach the right people at the right time.
Implemented effectively, Martha’s Rule can strengthen communication, accountability and patient involvement across deteriorating patient pathways.
The introduction of Martha’s Rule marks a significant development in patient safety within the NHS. This article looks at the what, why, and how of Martha’s rule, the resources needed for its implementation, and its potential impact on the future of NHS patient care.
Announced in September 2023, Martha’s Rule is a patient safety measure that empowers patients and their families to directly request a second opinion from a senior clinician if they feel their concerns about a patient’s condition are not being adequately addressed by the initial healthcare team. The rule was named after 13-year-old Martha Mills, after her sepsis symptoms were not recognised by medical staff in time to save her life. Her parents, Merope Mills and Paul Laity, have since campaigned for changes in how the NHS handles patient safety, leading to the creation of this rule.
Martha’s Rule was created to keep patients safe and build trust between the NHS, its patients and their families. It acts as a mechanism that allows patients and families to voice concerns that may otherwise go unheard, reducing the chance of missed information and increasing patient advocacy.
The case of Martha Mills wasn’t an isolated one, rather something that highlighted systemic issues within the NHS, particularly in recognising and escalating concerns about deteriorating patients. Her parents repeatedly expressed concern about her worsening condition, but their worries were not sufficiently addressed until it was too late. The rule aims to prevent further tragedies by giving patients and families a clear, formalised pathway to request a second opinion when they feel something is wrong.
Invoking Martha’s Rule is designed to be as straightforward and accessible as possible. Here’s how it typically works:
If a patient or their family believes that the patient’s condition is deteriorating and that these concerns are not being adequately addressed by the current medical team, they can invoke Martha’s Rule.
Once invoked, the hospital is obligated to facilitate a second opinion from a senior clinician who was not previously involved in the patient’s care.
The senior clinician will independently review the patient’s medical records, conduct a physical examination if necessary, and speak to both the patient and the family to understand their concerns.
Based on the second opinion of the senior clinician, the original clinician will either confirm the current treatment plan or recommend changes. The decision will then be communicated clearly to the patient and their family, and appropriate actions will be taken based on the clinician’s findings.
Implementing Martha’s Rule across NHS hospitals will require increased resources, which is why no date for introduction has been enforced and each hospital is able to adopt the rule at different times, based on readiness. Some hospitals may be more prepared to adopt the rule quickly, while others might face challenges with staffing, training or digital integration. The resources required for implementing Martha’s Rule include:
NHS staff must be trained on how to facilitate the process of Martha’s rule, as well as made to understand its importance. This should include anyone involved in the process at all, so not only frontline clinical staff but also administrative personnel who may help in coordinating the second opinion. Awareness campaigns within hospitals will be necessary to ensure that both staff and patients are informed about the rule and how it can be used.
To meet the requirements of Martha’s Rule, hospitals may need to increase the availability of senior clinicians who can provide second opinions. This could involve recruiting more senior doctors or ensuring that existing senior staff are available on-call for such situations, either individually or as part of a dedicated team. Since deteriorating patients may be involved, ensuring that the process is swift is crucial to its effectiveness. This means that comprehensive resources must be allocated to prevent delays.
The implementation of Martha’s Rule will also require robust digital infrastructure. Digital communications or electronic patient records (EPR) systems will need to be equipped to flag requests for second opinions quickly and ensure that all relevant patient information is accessible to the senior clinician providing the second opinion. Integrating Martha’s Rule into existing digital workflows will help streamline the process and reduce administrative burdens.
Patients and families must be informed about their rights under Martha’s Rule, so they know that they can use it if and when they need to. Hospitals will need to provide clear, accessible information about how to invoke the rule, what to expect, and who to contact. This might involve printed materials, digital resources, and direct communication from healthcare providers.
Martha’s Rule has the potential to significantly improve patient safety within the NHS by giving patients and families a formal mechanism to escalate concerns. Earlier interventions in cases where a patient’s condition is deteriorating have the potential to save lives and increase trust between doctors, their patients and their families.
For NHS staff, Martha’s Rule can serve as a supportive tool, encouraging a culture of transparency and openness. Knowing that patients and families have the right to request a second opinion may also motivate clinicians to be more vigilant and responsive to concerns, improving outcomes for everyone involved.
The rule doesn’t, however, come without its challenges. The requirement for additional senior clinicians to provide second opinions might strain already overburdened NHS staff. This would lead to increased workloads, especially in hospitals that are already experiencing staffing shortages.
Moreover, there could be tensions between healthcare professionals if the second opinion differs significantly from the initial assessment, or if a clinician strongly believes that no second opinion is necessary. This could create challenges in team dynamics and require careful management to ensure that the focus remains on patient safety rather than professional disagreements.
There is also the potential for increased administrative burdens, particularly if the digital infrastructure is not fully equipped to handle the new processes. This can be resolved, however, by investing time into digital transformation, something which will have knock on benefits in other areas across the Trust.
