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Martha's Rule represents one of the most significant patient safety initiatives introduced across English NHS trusts in recent years. Designed by NHS England to ensure that patients, families and staff can raise concerns about deterioration and receive an appropriate response, Martha’s Rule aims to strengthen communication, support earlier recognition of deterioration and amplify patient and family voices. The policy rule was first introduced in June 2024 across 143 pilot sites. As implementation continues across England, independent researchers undertaking national evaluation pause to consider: What have we learned from early implementation of Martha's Rule in real-world NHS settings? What challenges have emerged alongside the successes? How has the formative evaluation already influenced policy developments? What questions can only be answered through the forthcoming summative evaluation? About this webinar In this webinar, researchers from the NIHR Policy Research Unit Quality Safety Outcomes of Health and Social Care (NIHR QSO PRU) will share key interim findings from the formative evaluation of Martha’s Rule, drawing on in-depth ethnographic research, involving interviews, observations, and documentary analysis undertaken across three NHS pilot sites, as well as public survey data (collected in partnership with Picker and YouGov). The session will explore how organisations have implemented Martha's Rule within different local contexts, the opportunities it has created for improving communication and collaborative care, and the practical challenges encountered during implementation. The webinar will also look ahead to the newly commissioned national summative evaluation to be delivered by the NIHR SafetyNet - The Patient Safety Research Collaboration Network. Building on the learning from the formative work, this large-scale mixed-methods evaluation has been designed to assess the implementation, effectiveness, impact and value of Martha's Rule as it is adopted more widely across England. In other words, it will explore which aspects of Martha's Rule work well, for whom, under what circumstances and why, generating evidence to inform future national policy and practice. Attendees will gain insight into the realities of implementing complex safety interventions at scale, the importance of learning during implementation, and how robust evaluation can support evidence-informed policy, practice and continuous improvement. This is a joint webinar hosted by Patient Safety Learning in collaboration with NIHR SafetyNet – The Patient Safety Research Collaboration Network. Presenters Professor Rebecca Lawton Rebecca is Professor, Psychology of Healthcare at the University of Leeds, UK and an NIHR Senior Investigator. She is a behavioural scientist and patient safety researcher. Rebecca is Director of the NIHR Yorkshire and Humber Patient Safety Research Collaboration and leads the NIHR SafetyNet, which brings together all six of the PSRCs in England to co-ordinate shared learning, PPIE/EDI, safety equity research, impact and dissemination. She also leads on Safety within the national Policy Research Unit for Quality, Safety and Outcomes in England, the team that delivered the Martha’s Rule formative evaluation. As Director of the Yorkshire Quality and Safety Research Group of over 45 researchers and PhD students, Rebecca and her team focus on ‘delivering research that makes care safer’. Rebecca is a leading patient safety academic whose track record of patient safety solutions informed by theory and evidence has generated significant international impact. She has over 250 publications in leading journals, successful doctoral and post-doctoral supervision of 23 early career researchers and external funding as PI of over £25million. Dr Lavanya Thana Lavanya is a Senior Policy Research Fellow with the NIHR Policy Research Unit for Quality, Safety and Outcomes in Health and Social Care (NIHR QSO PRU) and the Yorkshire Quality and Safety Research group in the UK. As a qualitative research psychologist with over 15 years of experience, her projects span patient safety, implementation science, and the evaluation of complex interventions in acute, primary, community and mental health settings. Her current research focuses on understanding how healthcare policies and innovations are implemented in practice, with particular interests in patient and staff experience, person-centred care, addressing inequalities, and improving the quality and safety of care. Lavanya leads the delivery of the independent formative evaluation of Martha's Rule, working with a team of researchers and external partners to understand public awareness, how the policy is being implemented across NHS organisations, the factors influencing its delivery, and how early learning can support national rollout. She also contributes to the design and delivery of the qualitative workstream of the national summative evaluation, which will assess the impact and effectiveness of Martha's Rule across England. Register

This newly renamed annual meeting is designed to give health care leaders, advocates and innovators -- who are shaping the future of patient safety -- even more opportunities to connect, gain valuable knowledge, and celebrate. Join Leapfrog’s unusually diverse group of attendees, including senior leaders from hospitals, ASCs, employers, health plans, patient safety organizations, patient and family advocates, researchers, and aligned national nonprofits. WHY SHOULD YOU ATTEND? New breakout sessions on trending topics, including: Hospital Boarding in the Emergency Department (ED) Patient and Family Partnership in Care Delivery Advancing Quality in ASCs and Outpatient Care Leadership Lessons from High-Performing Hospitals Register

This week the new Quality strategy for NHS-funded care in England has been issued. This has been published by NHS England on behalf of the National Quality Board (NQB), the principle national forum for quality across the healthcare system in England. The NQB brings together leaders from NHS England, the Department of Health and Social Care (DHSC), arm’s length bodies and clinical leadership. In this article, Patient Safety Learning sets out its initial reflections on the new Quality Strategy. On Tuesday 14 July 2026 a new Quality Strategy was published by the NQB. This document is intended to provide a structured approach to making quality the organising principle for all NHS activity over the next 10 years. At Patient Safety Learning, we believe that improving patient safety in inextricably linked to this aim. The new Strategy builds on last year’s Review of patient safety across the health and care landscape in England. We agreed with the Review’s recognition of the need to coordinate and rationalise the patient safety landscape. However, we have also expressed concerns about some of its content. In particular, we contested its argument that patient safety has been significantly over prioritised in recent years at the expense of other aspects of quality. As noted in our response to the review, we do not believe the examples it gave provided compelling evidence of this. Furthermore, we strongly believe that you cannot build an effective, efficient and responsive NHS on an unsafe system. In the coming weeks we will publish a more detailed analysis of this new Quality Strategy; however, in this article we will share our early reflections on the direction and content. Where we agree and welcome its approach We welcome the publication of the new Quality Strategy and the opportunity that it presents to improve patient care, experiences and outcomes. Priorities We are supportive of the six priorities identified by the new Strategy, and particularly the inclusion of a specific reference to patient safety. The priorities are: Improving outcomes and reducing unwarranted variation across major conditions and priority groups through implementation of the National Cancer Plan and modern service frameworks. Making sustained improvements in maternity and neonatal services. Strengthening patient safety across all settings. Improving experience of care and restoring trust in NHS services. Reducing inequalities across safety, effectiveness and experience. Monitoring clinical and population health outcomes. Clarifying who is responsible and accountable for quality Given the number of organisational changes in recent years, we are pleased to see the Strategy provides a clear outline of roles and responsibilities for quality management among different parts of the health system. Identifying patient safety risks We welcome proposals to explore how artificial intelligence and other advanced digital technologies can help the NHS learn more quickly when things go wrong and identify emerging risks earlier. Updating the Patient Safety Strategy We await with interest the publication of a reviewed and refreshed NHS Patient Safety Strategy. Looking ahead to this: It is positive that there is a recognition of the need to integrate digital safety considerations into the updated document. We would echo comments made in by the Health Services Safety Investigations Body (HSSIB) about reviewing the Patient Safety Strategy with a view to bringing together quality management and safety management. The Quality Strategy rightly acknowledges these as different but connected approaches. We believe these should be brought together, as part of an integrated quality and safety management system. Where we have concerns Recognition and prevention of avoidable harm We are disappointed that in setting the context for this Strategy, the scale and persistence of avoidable harm is not mentioned. Given the findings of numerous public inquiries and rising clinical negligence costs, the omission of avoidable harm as a factor for consideration is a significant oversight in our view. We are also disappointed that there is also no explicit ambition to reduce avoidable harm, beyond the following statement: “Improving safety in healthcare involves reducing the risk of unintended and unexpected harm to patients, while recognising that all care carries some level of risk. It does not mean eliminating all risk or pursuing zero harm.” We have concerns that this could, understandably, be considered alarming by many, including those patients and families where harm is preventable but is not being prioritised. We also have concerns about how this approach sits along the statutory obligations of providers to provide safe care and treatment (set out in the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014). National learning and improvement Patient Safety Learning believes that there needs to be structured systematic approaches to learning about the cause and contributory factors of avoidable harm. We need to better understand the action that is needed to develop solutions and improvement action in the NHS. Accompanying this, there should be capacity at a national level to: Share widely learning from investigations and learning responses to patient safety incidents. Intervene if necessary for the purposes of improvement. Develop solutions to improve safety and share these systematically. The Strategy does not appear currently to envision any such role for either the Department of Health and Social Care (DHSC), NHS England or the National Quality Board (NQB). The absence of this national capacity is a gap we also highlighted in our responses to Penny Dash’s patient safety review and the 10 Year Health Plan last year. Culture We believe there needs to be a transformative effort and commitment to creating a safety culture in the health service. We are disappointed that this has not been given greater consideration in the Quality Strategy, despite the ambition being explicit in the NHS Patient Safety Strategy. There are significant changes needed to ensure that there is an open and fair culture, with a focus on learning and improvement that does not blame healthcare staff for systemic failings. Organisations need to actively foster a patient safety culture, tackle blame and fear, and promote a culture of safety improvement. Areas we believe need further consideration Involving and engaging with patients and families We believe there is room to develop in this Strategy greater detail on how patients and families can be supported and involved in improving quality and safety. The Quality Strategy tends to focus on the role of the new Directorate of Patient Experience in DHSC and better use of patient feedback mechanisms. We believe there should also be a greater emphasis on listening to patients, families, including bereaved relatives. Their concerns can often highlight risks that organisations have not identified or before they are aware of them. The Strategy puts on a welcome emphasis on increasing transparency. We believe this should be accompanied by stronger commitments to ensure openness and transparency when harm occurs. This includes honest communication with patients and families following safety incidents—an ambition often stated but not delivered. Coordination and improvement We would welcome further information about the roles of: Regional teams “co-ordinating involvement and intervention where necessary”. System Quality Groups supporting the management of quality across organisational boundaries by identifying early warning signs and “co-ordinating system action required to improve quality”. If these bodies are to take important roles in these areas we would expect to see plans to ensure they have the appropriate capacity and support to function in this way. This is particularly important in the context of the changing roles and reduced resources with the current NHS organisational changes Monitoring recommendations There remain significant questions around how the NQB will undertake its new role maintaining and monitoring national recommendations arising from reports, reviews, inquiries and investigations. We understand the development of a new “recommendations hub”, mentioned in the Strategy, is already underway, and we await to see what this will look like in practice. There remain unanswered questions about how this will work and what level of transparency there will be around which recommendations are prioritised for implementation. This will be important given concerns which have been raised about how the transfer of HSSIB’s functions to the Care Quality Commission may impact the independence of future investigations. Questions about implementation The new Quality Strategy contains a detailed list of requirements, opportunities, imperatives and suggestions. However, many questions remain about what its implementation will look like and the impact this will have on patient and staff safety. At Patient Safety Learning, we recognise challenges organisations face in implementing changes in quality and patient safety. We have been engaging with organisations through our “What Good Looks Like” for patient safety, drawing on our report A Blueprint for Action. We believe this framework could help to potentially underpin significant elements of the implementation of the broad commitments in the new Quality Strategy. While the existing Strategy does include some specific activities, with broad timescales, we would expect to see more developed plans subsequently setting out how this will be delivered. This should be accompanied with details on the initial areas that will be prioritised and what key success criteria will be for delivering quality and safety improvements.

We often hear from the Patient Safety Management Network that members are in interested in how others from different industries do things. In this hub top picks, we have pulled together useful websites on safety and investigations in other industries, including aviation, rail, nuclear and defence. Aviation safety Air Accidents Investigation Branch (AAIB) AAIB Reports Collection National Transportation Safety Board (NTSB) NTSB Aviation Accident Database ASRS - Aviation Safety Reporting System European Union Aviation Safety Agency (EASA) EASA Safety Publications Safety - International Civil Aviation Organization BEA Safety Hub - France Confidential Human Factors Incident Reporting Programme (CHIRP) SKYbrary Aviation Safety THE NIMROD REVIEW An independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006 HC 1025 Aircraft Accident Report AAR 2/2023 - Sikorsky S-92A, G-MCGY Defence Defence Accident Investigation Branch (DAIB) Defence Safety Authority (DSA) Service Inquiries (SI) Ministry of Defence Service Inquiries Safety Assessment Principles (SAPs) - Office for Nuclear Regulation Guide to Service Inquiries Marine safety Marine Accident Investigation Branch International Maritime Organization Marine Safety Investigation Reports Nuclear industry safety International Atomic Energy Agency (IAEA) IAEA Safety Reports Series World Association of Nuclear Operators (WANO) The Public Inquiry into the Piper Alpha Disaster: Volume 1 Oil and gas and major accidents Energy institute Deepwater Horizon Investigation Report Rail safety Rail Safety and Standards Board (RSSB) Rail Accident Investigation Branch Reporting railway incidents - Office of Rail and Road Related reading See our Good practice from other industries category on the hub for more resources and reading. Do you have any safety resources from other industries that you have adapted to use in your organisation? We'd love to share them on the hub. Comment below (you'll need to be a hub member—sign up is free and easy to do) or email [email protected].

Sebastian Gonzalez, hub topic lead and learning disability lead nurse at Barts Health NHS Trust, reflects on the lack of progress made in reducing health inequalities for people with a learning disability despite a number of reports and recommendations over the last few years. He highlights the new reasonable adjustment digital flag that is being implemented across the NHS, which allows the sharing of detailed information across the healthcare system about the reasonable adjustments individuals require. Sebastian asks you to explore what your organisation is doing to implement the reasonable adjustment digital flag to help identify and support patients with a learning disability. Since the publication of the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD),[1] we have been aware of the profound health inequalities across the country. Currently, it is estimated that 1.5 million people with a learning disability live in the UK,[2] and more recent data show that, on average, adults with a learning disability die 19.5 years earlier than the general population and that 40.2% of their deaths are considered avoidable.[3] The National Confidential Enquiry into Patient Outcome and Death report The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is a UK based charity that reviews the quality of healthcare in order to improve patient safety and outcomes. In 2026 they published a study report: Learning Together: A Review of the Quality of Care Provided to Adults with a Learning Disability When Admitted to Hospital Acutely Unwell (NCEPOD).[4] More than a decade after CIPOLD first exposed the health inequalities experienced by people with a learning disability, the findings of this report demonstrate that significant challenges remain and that further action is needed to improve patient safety and healthcare outcomes. The study focused on adults aged 18 years and over with a learning disability who were admitted to hospital as an emergency between 1 July and 30 September 2024. Data were gathered from a range of sources, including clinician questionnaires, primary care questionnaires, organisational questionnaires, surveys completed by healthcare professionals, patients and carers, and detailed reviews of patient case notes. Key findings: Incorrect use of the terms learning disability and learning difficulty. Underuse of flagging and alert systems. Failure to consistently implement reasonable adjustments. Poor adherence to the Mental Capacity Act. Limited involvement of people with a learning disability in their own care decisions. Unequal access to specialist learning disability services. A focus on flagging and alert systems The study found that hospital services often failed to accurately identify and flag people with a learning disability. One of the key expectations introduced in 2018 through the Learning Disability Improvement Standards for NHS Trusts was that organisations should have mechanisms in place to identify and flag patients with a learning disability, autism, or both, from the point of admission through to discharge. Yet, the report highlighted that while 89.7% of the organisations reported having flagging or alert systems in place, only 52.2% of patients had these alerts. The issues were compounded by the incorrect use of the term learning difficulty, an issue well known to people with a learning disability and those that support them.[5] Furthermore, the report identified a key link between the use of flags and the provision of reasonable adjustments, highlighting how adjustments were more likely to be made when patients had been accurately identified and flagged. Moving forward Throughout the years, several reports have provided evidence of the poorer outcomes experienced by people with a learning disability and have made recommendations on how to improve their care. Despite this, it remains clear that there is still a long way to go in reducing the health inequalities experienced by this patient group. While the process of identifying and flagging patients may seem administrative in nature, it represents an essential patient safety mechanism that helps ensure individuals receive healthcare that is reasonably adjusted to meet their needs. In addition, an effective flagging system enables organisations to monitor outcomes closely, including incidents involving this group of patients. This, in turn, can support more effective service planning and ultimately contribute to improved patient outcomes. The reasonable adjustment digital flag[6] being implemented across the NHS represents an opportunity to go beyond simply identifying and flagging patients. Not only does it allow for detailed information about the reasonable adjustments individuals require, but it also promotes the sharing of this information across the healthcare system. If your role involves improving patient safety, consider exploring what your organisation is doing to implement the reasonable adjustment digital flag, and how it identifies patients with a learning disability and ensures they receive the support they need. Small changes in these areas have the potential to make a significant difference to patient experience and outcomes. References Heslop P, et al. Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD) Final report. Norah Fry Research Centre, 2013. Mencap. Learning Disability Research and Statistics. Last accessed 5 July 2026. White SA, et al. LeDeR Annual Report Learning from Lives and Deaths: People with a Learning Disability and Autistic People. The Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London. Last update June 2026. Tavaré A. Learning Together A review of the quality of care provided to adults with a learning disability when admitted to hospital acutely unwell. NCEPOD, 2026. Mencap. Learning Difficulties: Types, Causes and Symptoms. Last accessed 5 July 2026). NHS England. The reasonable adjustment digital flag action checklist: what you need to do to achieve compliance. 25 March 2024.

NHS Resolution is an arm’s length body of the Department of Health and Social Care. It provides expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care. It handles negligence claims on behalf of NHS organisations and independent sector providers of NHS care. Their annual report and accounts for 2025/26 reflects on the first year of their three-year strategy, Resolution Through Collaboration, providing an overview of the work of NHS Resolution over this period. Key points highlighted in this report include: There has been in increase in new clinical claims received, which totalled 15,236 in 2025/26 (up from 14,428 claims in 2024/25). 84% of clinical claims were kept out of formal court proceedings, providing earlier resolution for patients and healthcare staff, and saving costs. £3.2 billion was paid out in 2025/26 for compensation and associated costs on all of NHS Resolution’s clinical schemes (up from £3.1 billion in 2024/2025 and £2.8 billion in 2023/24). 40% (£1.3bn) of the total clinical negligence payments (£3.2bn) in 2025/26 related to maternity. This is a reduction from 42% in 2024/25. The estimated total cost of harm incurred in 2025/26 was £4.8 billion. The majority of this related to the main clinical scheme, the Clinical Negligence Scheme for Trusts, which was £4.5 billion. NHS Resolution’s provision for future liabilities as of 31 March 2026 was £60.3 billion.