Martha’s Rule: When “Something Is Wrong” Must Be Heard

A patient’s observations appear relatively stable, but their family is convinced that something has changed.

“They are not normally this sleepy.”

“Their breathing looks different.”

“They are getting worse, and nobody is listening.”

These statements should never be dismissed as anxiety or interference. A relative who knows the patient well may recognise a meaningful change before it becomes obvious in routine observations.

Martha’s Rule was introduced to provide an additional safety route when a patient appears to be deteriorating and concerns are not receiving an adequate response.

It gives patients, families, carers and healthcare staff a way to request a rapid review from a different clinical team.

Why was Martha’s Rule introduced?

Martha’s Rule was developed following the death of 13-year-old Martha Mills.

Martha was admitted to hospital in 2021 after sustaining a pancreatic injury in a bicycle accident. Her condition later deteriorated and she developed sepsis. Her family repeatedly raised concerns about the changes they could see.

A coroner subsequently concluded that Martha would probably have survived if she had been transferred to intensive care earlier.

Her case exposed a serious patient-safety problem: deterioration may be missed when clinical teams rely too heavily on routine measurements, fail to recognise developing patterns or do not give sufficient weight to concerns raised by patients and families.

Martha’s Rule is intended to make sure those concerns can reach another clinical team when the usual response has not resolved the problem.

What is Martha’s Rule?

Martha’s Rule is an NHS England patient-safety initiative supporting the earlier recognition and management of clinical deterioration.

It has three core components:

Patients must be asked regularly—at least daily in participating inpatient settings—how they feel and whether they believe they are improving or getting worse.
Staff must have access to a route for requesting a review from another clinical team when they are worried about deterioration and their concerns are not receiving an adequate response.
Patients, families, carers and advocates must also be able to request a rapid review when they remain worried that deterioration is not being recognised or addressed.

The review is normally undertaken by a team separate from the patient’s immediate treating team, such as a critical-care outreach or other designated clinical response team.

This provides a fresh assessment without requiring the patient or family to continue repeating the same concern to the same people.

How does it work?

The precise process varies between hospitals because there is no single national Martha’s Rule telephone number.

A typical process follows these stages:

A concern is raised

The patient, relative, carer or member of staff reports that the patient appears to be getting worse.

The immediate care team should listen, assess the patient, review observations and respond to the concern.

The concern remains unresolved

The patient or family may feel that the response has not addressed what they are seeing. A member of staff may also remain concerned after escalating through the normal clinical pathway.

They should not be required to prove that the patient is deteriorating before seeking further help.

A rapid review is requested

The hospital’s dedicated Martha’s Rule contact number or local escalation process is used.

Contact details should be available through ward posters, patient information or the hospital’s website. Patients and families can also ask ward staff whether Martha’s Rule is available and how to access it.

A different clinical team reviews the patient

The reviewing team independently reassesses the patient, listens to the concerns raised and examines the available clinical information.

The review may confirm that the existing care plan is appropriate, or it may identify a need for additional monitoring, investigations, treatment, specialist input or transfer to a higher level of care.

The outcome is communicated and documented

The patient and family should be informed about the outcome. The concern, assessment, decision and action taken must be documented clearly.

How can Martha’s Rule help save lives?

Martha’s Rule does not guarantee that every deteriorating patient will survive. Making that claim would be inaccurate.

Its life-saving potential comes from reducing delays.

Deterioration does not always begin with a dramatic change in an observation score. Early signs may include unusual behaviour, increasing pain, subtle breathing changes, reduced interaction, new confusion or a general change that is obvious only to someone familiar with the patient.

NHS England data covering September 2024 to June 2026 recorded 17,490 Martha’s Rule calls. Of these, 5,299 related to acute deterioration and 3,174 resulted in a change to treatment. This included 685 escalations involving transfer to higher-dependency, intensive, tertiary or specialist care.

NHS England also reported that, between June 2025 and June 2026, 82% of Martha’s Rule calls concerning acute deterioration would not have triggered escalation through the early-warning score alone.

This does not mean observation scores are ineffective. It demonstrates that measurements and human concern identify different parts of the clinical picture.

Martha’s Rule strengthens safety by bringing them together.

An illustrative example

An adult patient is recovering after abdominal surgery. Their observations do not initially meet the threshold for an emergency response.

The patient’s daughter tells staff that they are becoming unusually withdrawn, struggling to answer questions and behaving very differently from their normal pattern.

The patient is reviewed, but the daughter remains concerned that the deterioration has not been adequately explained.

She uses the hospital’s Martha’s Rule process. A separate clinical team reassesses the patient, examines the observation trends and orders additional investigations. Treatment and monitoring are escalated.

This example does not suggest that every concern indicates a medical emergency. It shows how an additional review can identify deterioration earlier or provide reassurance based on a fresh clinical assessment.

What nurses must know

Listen without becoming defensive

A family member raising a concern is not automatically criticising the nurse.

Statements such as “this is not normal for them” may provide clinically relevant baseline information. Ask what has changed, when it started and why the person believes it is significant.

Assess and escalate immediately

Martha’s Rule must never replace normal nursing action.

If deterioration is suspected, assess the patient, obtain appropriate observations, review trends and use the organisation’s established escalation pathway. Urgent or emergency treatment must not be delayed while someone looks for the Martha’s Rule telephone number.

Do not obstruct access

Patients and families should not be discouraged from using Martha’s Rule because the nurse believes the current plan is sufficient.

A nurse can explain the care already provided, but should not act as a gatekeeper or require the family to obtain permission from the treating team.

Use the route yourself

Martha’s Rule is not limited to patients and relatives. Staff can request a rapid review when they believe a patient is deteriorating and their concerns are not receiving an adequate response.

A healthcare assistant, nurse, nursing associate or other professional should not remain silent because someone more senior has dismissed the concern.

Document the concern accurately

Record:

Who raised the concern.
Their exact description of the change.
When the change was first noticed.
Relevant observations and trends.
Assessments completed.
Who was informed and when.
Advice, decisions and actions taken.
Whether a rapid review was requested.
The outcome and ongoing monitoring plan.

Avoid entries such as “family anxious” without documenting what the family actually observed.

Support accessible communication

Some patients may be unable to raise concerns independently because of dementia, learning disability, delirium, communication difficulty, language needs or reduced consciousness.

Staff should support relatives, carers, advocates and interpreters to communicate relevant concerns. The patient’s communication needs must not become a barrier to escalation.

Cooperate with the reviewing team

A rapid review should not be treated as a challenge to professional authority.

Provide an accurate handover, current observations, relevant trends, treatment information and the concern raised. Continue delivering necessary care while the review is completed.

What adult social care professionals should know

Martha’s Rule is currently centred on NHS inpatient services. It should not be advertised as a universal care-home, domiciliary-care or community service.

If someone deteriorates in an adult social care setting, staff must continue to use the organisation’s emergency and clinical-escalation procedures. Depending on the situation, this may include contacting the registered nurse, GP, urgent community service, NHS 111 or 999.

Do not delay urgent assistance while trying to use a hospital-based Martha’s Rule process.

However, adult social care professionals still have an important role:

Provide clear baseline information when a person is admitted.
Explain how the person usually communicates and behaves.
Identify recent changes in cognition, mobility, eating, drinking or continence.
Ensure medication and care information accompanies the person.
Help relatives understand that they can ask whether Martha’s Rule operates in the admitting hospital.
Continue advocating when deterioration concerns remain unresolved.

What Martha’s Rule is not

Martha’s Rule is not:

A replacement for emergency clinical escalation.
A substitute for routine observations or professional judgement.
A complaints procedure.
A disciplinary process against staff.
A guarantee that the reviewing team will change treatment.
The same as requesting a formal second opinion.
A service currently available in every health and social care setting.

It is an additional safety net focused on possible clinical deterioration.

Is Martha’s Rule a legal requirement?

Martha’s Rule is not an Act of Parliament and should not be described as new legislation.

It is an NHS England patient-safety initiative. The NHS Standard Contract 2026/27 requires NHS trusts and NHS foundation trusts to implement its three core components by 31 March 2027.

Implementation may therefore differ between hospitals while the national rollout continues.

Nurses must also continue to follow the professional requirements of the NMC Code, including prioritising people, practising effectively, preserving safety and raising concerns when patient safety may be at risk.

The essential message

Martha’s Rule does not undermine nurses or replace clinical judgement.

It recognises a hard truth: healthcare systems can miss deterioration, and professional hierarchy can sometimes prevent legitimate concerns from being heard.

The safest response to “something is wrong” is not defensiveness.

It is curiosity, reassessment, documentation and appropriate escalation.

When patients, families and staff are heard early enough, the outcome can change.