Martha's Rule is a patient safety initiative that supports the early detection of deterioration by ensuring the concerns of patients, families, carers, and staff are listened to and acted upon.
Martha Mills, aged 13, sadly died in 2021 after developing sepsis in hospital, following a pancreatic injury she suffered after falling off her bike. Martha's family were concerned about the treatment she received and the deterioration of her condition. In 2023, a Coroner ruled that Martha would probably have survived had she been moved to intensive care earlier.
Following the outcome in Martha's case 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.
Implementation of Martha's Rule
In March 2026, NHS England published an article advising that Martha's Rule has now been included in the NHS Standard Contract. Patient Safety of the NHS Standard Contract 2026/2027 requires all NHS Trusts and NHS foundation trusts to implement the 3 core components of Martha's Rule by 31 March 2027.
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.
Using Martha's Rule
Knowing that an escalation route exists is only useful if you know how to use it. If you are on a ward and concerned that a patient's condition is deteriorating, the process generally works as follows:
- Raise the concern with ward staff first. In most cases, simply telling a nurse or doctor that you think the patient is getting worse is enough to trigger a review. Be specific: describe what has changed, since when, and why it concerns you.
- If you are not satisfied with the response, ask to use Martha's Rule (or your hospital's equivalent, sometimes called Call for Concern). You do not need permission from ward staff to do this, and you should not need to justify why you are escalating beyond explaining your concern.
- Find the escalation contact for that specific hospital. There is no single national Martha's Rule number, each NHS Trust and NHS foundation trust has its own dedicated phone number or contact route. You can find this by checking the hospital's website, looking for posters displayed on the ward, or asking any member of staff directly.
- A review will be carried out by a different team, typically a critical care outreach team, independent of the ward staff currently treating the patient. This is intended to give a fresh clinical assessment, separate from the team you have already raised concerns with.
- What happens next depends on the outcome of the review. This can range from reassurance and a plan for continued monitoring, through to a change in treatment, transfer to a higher level of care, or referral to a specialist, as reflected in the data below.
A few practical points worth knowing:
- You can use Martha's Rule at any time, not only during a clinical crisis. It is designed to be used as soon as you have a concern, not as a last resort.
- Staff should not need convincing before agreeing to escalate. If you feel resistance, you are still entitled to ask for the review.
- Escalating a concern is not a complaint about staff, it is a request for a second clinical opinion, and hospitals are expected to treat it as such.
If a hospital does not yet have a visible Martha's Rule process advertised, you can still ask to speak to PALS (the Patient Advice and Liaison Service) or request a senior review directly.
Data collected
As per the article published by NHS England in March 2026, early evidence suggests Martha's Rule is saving lives and helping thousands of patients benefit from changes to their care.
The article advised that the data collected from September 2024 to April 2026 revealed 14,654 Martha's Rule calls were made, with the highest proportion of calls (72%) made via the family/carer escalation process and 4,632 Martha's Rule escalation calls (32%) related to acute deterioration.
Furthermore, 2,720 of those calls required changes in patients' treatment. This included 616 calls which resulted in transfers of care to high dependency or intensive care units, enhanced levels of care, tertiary centres or referral/transfer to specialists or a specialist ward. Other changes in treatment (2,104) did not require transfer of a patient from a ward in-patient setting. This included the introduction of a new medication, such as an antibiotic to treat infection, investigations, including scans, and procedural interventions, including going to theatre. Where calls were not categorised as being related to acute deterioration, they are still supporting staff to provide better care and address concerns.
What does this mean in practice?
Roughly 1 in 5 calls led to a change in treatment, and around 1 in 24 calls led to a transfer to a higher level of care. In other words, escalation is far from a rare or last-resort step, it is a meaningful clinical safeguard that is regularly changing the course of a patient's care.
"Some medical negligence claims arise from a failure to listen and escalate treatment when a patient is deteriorating. I think the introduction of Martha's Rule reinforces the importance of listening and investigating a patient's concerns. Martha's Rule serves a powerful reminder that patients, their families and carers are often the first to recognise when something is wrong and acting upon their concerns may prevent avoidable harm."
Mia Clews
Legal Assistant - Medical Negligence
If you believe concerns were not acted upon
If you or a loved one raised concerns about deteriorating care and feel they were not acted upon in time, our medical negligence lawyers can advise you on whether this may form the basis of a claim.
Frequently asked questions
Martha's Rule is a contractual requirement under the NHS Standard Contract 2026/2027, meaning NHS Trusts and NHS foundation trusts are required to implement it by 31 March 2027. It is not, in itself, a piece of legislation, but a failure to follow it could still be relevant to how a trust's conduct is judged in a medical negligence claim.
No. Although it was introduced following the death of a 13-year-old, Martha's Rule applies across NHS hospitals to patients of all ages, as well as to their families, carers, and hospital staff.
Trusts have until 31 March 2027 to fully implement the three core components. If a formal Martha's Rule process is not yet visible, you can still ask directly for a senior review, or contact the hospital's Patient Advice and Liaison Service (PALS) to raise your concern.
The core components of Martha's Rule require that the escalation route is always available to patients, families and carers, and advertised across the hospital. If you feel a request for review is being refused or dismissed, you can ask to speak to a more senior member of staff or PALS.
From a medical negligence perspective, as Martha's Rule is implemented into all NHS Trusts and NHS foundation trusts, we hope to see that if there are concerns with a patient's treatment, their concerns are heard, escalated and acted upon promptly.
Further, as Martha's Rule becomes embedded within NHS practice, it may become relevant in future medical negligence claims as it may be argued that:
- The trust failed to follow Martha's Rule.
- A patient's or family's concerns were not appropriately documented or investigated.
- An earlier rapid review would likely have prevented injury or death.
This information is for guidance purposes only and does not constitute legal advice. We recommend you seek legal advice before acting on any information given.
