Martha's Rule: What is it and why does it matter?

What is Martha’s Rule?

The aim of Martha’s Rule is to give patients in NHS hospitals (and those acting on their behalf) the right to request a rapid review from another team at the same hospital if it is felt that they are deteriorating but action has not been taken, or it appears that concerns are not being taken sufficiently seriously by medical staff. This is not the same as a second opinion which would usually be provided by other clinicians in the same treating field and not as urgently.

Background to Martha’s Rule

The rule is named after Martha Mills, who died in 2021, aged 13, at the King’s College Hospital NHS Foundation Trust. She had been admitted with a pancreatic injury after falling off her bicycle, but she sadly died when her parents’ concerns about sepsis were not acted upon. In 2022, a coroner ruled that Martha would most likely have survived if she had been transferred to intensive care earlier.

Martha’s mother recounts her experiences and the events that unfolded in the foreword to a September 2023 report published by the policy think tank Demos. The Demos report made three core recommendations:

• NHS England (NHSE) should develop best practice guidance to allow hospitals to adopt this system as soon as possible.

• Hospitals should adopt Martha’s Rule as a matter of urgency and communicate it clearly to patients.

• The Care Quality Commission should consider Martha’s Rule standard practice in inspections and include their implementation in any inspections.

The then Health Secretary, Steve Barclay, confirmed the Government’s commitment to introducing Martha’s Rule, a major patient safety initiative giving hospital patients in England the legal right to request a rapid review.

The Patient Safety Commissioner was asked to convene NHS leaders to consider the proposals and gather evidence from NHS Trusts where there are already such schemes.

Existing obligations and schemes

The General Medical Council (GMC’s) guidance ‘Good Medical Practice’ (published in 2024) states that doctors must “respect the patient’s right to seek a second opinion”. As stated however, a second opinion is not the same as a rapid review under Martha’s Rule. There are similar schemes which seek to ensure that the concerns of patients, or those acting on their behalf, are heard. For example:

• Call 4 Concern was pioneered by the Royal Berkshire NHS Trust in 2009/2010 and subsequently adopted by a number of NHS trusts. It allows patients and relatives to call upon the hospital’s critical care outreach team at any time of the day if they are concerned about a change in condition they feel is not being recognised. A review at the Royal Berkshire (in 2019) found the service had been used 534 times in seven years, and 95% of the calls placed were using the service appropriately. In a fifth of cases, significant interventions were required.
• Ryan’s rule was established in Queensland, Australia following the death of Ryan Saunders, who died in 2007 from an undiagnosed Streptococcal infection which led to Toxic Shock Syndrome. Ryan’s rule gives patients of any age, their families and carers, the legal right to request an urgent second medical opinion if a patient’s condition is getting worse or not improving as well as expected and they feel their concerns are being dismissed. Ryan’s rule applies to patients admitted to any Queensland Health public hospital and has proved successful in saving lives.
• The National Australian Charter of Healthcare Rights also includes a right for patients, families and carers to obtain a second medical opinion from another healthcare provider, or expert, if they have concerns about the treatment options offered.

How does Martha’s Rule work?

In December 2024, NHSE set out their response to Martha’s Rule, confirming that the three components of Martha’s Rule are as follows:

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.

1. Martha’s Rule can be invoked in a wide range of circumstances across multiple medical and surgical specialities. NHS trusts will need to plan carefully to ensure that requests for a review are acted upon promptly and appropriately.
2. Hospitals currently without a critical care outreach (or similar) team will need to establish them, and existing teams may need to upskill, recruit or redeploy staff to ensure the necessary capacity to deliver Martha’s Rule. 
3. The plan is to ultimately roll out Martha’s Rule across the NHS in England. However, the trial and implementation of Martha’s Rule could lead to different processes from those currently envisaged.

Progress of implementation of Martha’s Rule to date 

In April 2024, a joint statement was issued by the Nursing and Midwifery Council (NMC), GMC and Care Quality Commission (CQC) of their support for the implementation of Martha’s Rule. They confirmed that “Martha's Rule aligns with the NMC's Code and the GMC's Good Medical Practice, which set out the standards of care and behaviour expected of all the professions we regulate.” 

In May 2024, NHSE announced the 143 hospitals in England that would receive funding to be the first test sites for Martha’s Rule following successful expressions of interest. This first phase was planned to be in place by March 2025. 

In December 2024, NHSE also advised that the introduction of Martha’s Rule is being implemented alongside other patient safety measures improving the identification of deterioration. This includes the rollout in November 2024 of an early warning system for staff treating children. 

On 17 December 2024 it was announced that Martha’s Rule had already begun triggering “potentially lifesaving changes in care” for patients. Of the 143 hospital sites implementing Martha’s Rule in the first year, early data was returned by 136 sites, including 87 sites which had implemented an escalation process for patients and families so far, and 92 sites that had partially or fully implemented an escalation process for staff. The early data they quote from participating hospital sites across England showed that:

• At least 573 calls were made to escalate concerns about a patient’s condition deteriorating in September and October, including from patients, their family, carers and NHS staff.
• Around half (286/573) of these calls required a clinical review for acute deterioration, with around one in five (57/286) of the reviews leading to a change in the patient’s care – such as receiving potentially life-saving antibiotics, oxygen or other treatment – while remaining on their current wards.
• In addition, in the first two months alone, 14 calls made via the new Martha’s Rule initiative had resulted in a patient needing urgent transfer to an intensive care unit.

On 26 March 2025 the Patient Safety Commissioners for England, Dr Henriette Hughes, told the Commons health and social care committee that Martha’s rule was “improving safety” and “reducing harm”. MPs heard that thousands of patients or their loved ones have sought a review as result of hospitals adopting Martha’s Rule. This includes more than 100 patients taken to intensive care “or equivalent” since the patient safety procedure was introduced.

An increasing number of hospitals are now displaying the right to seek a rapid review under Martha’s Rule, so that patients/parents/carers are made aware of it without the need for the treating team to tell them. 
Even for NHS trusts not included in the first phase of implementation, we recommend they begin considering what changes, if any, they should make to deliver the safety benefits of Martha’s Rule. To improve patient safety, it is important for NHS trusts to collect audit data on when, why and how a rapid review under Martha’s Rule overturns the management decision that had been made by treating clinicians.

Careful consideration will need to be given to the availability of the team responding under Martha’s Rule, the process for such teams attending patients and how requests are prioritised and decisions documented. All NHS trusts should ensure that they have safe and robust processes for patients, families, carers, and staff to escalate concerns and support with seeking rapid reviews when indicated. Martha’s Rule should very much be welcomed by everyone as a highly significant patient safety initiative that trusts are seeking to embrace with the common aim of preventing harm.