Martha's Rule: A valuable patient safety tool facing new challenges

Summary

Martha’s Rule gives patients and families a vital way to escalate concerns when they believe a patient’s condition is deteriorating and they are not being heard. However, increased awareness of Martha’s Rule has also led to more calls about complaints, waiting times and other issues outside its intended scope.

In an anonymous blog, a critical care outreach nurse in an acute NHS Trust explains why, as the scheme expands, the NHS must preserve its patient-safety focus by setting clear expectations, providing suitable routes for other concerns and supporting staff who handle difficult calls.

Content

Recognising and responding to deterioration

Over the past year, Martha's Rule has become one of the most widely recognised patient safety initiatives in the NHS. Its purpose is simple but powerful: to provide patients, families, friends and carers with a way to escalate concerns when they believe a patient's condition is deteriorating and their worries are not being addressed.

The initiative emerged following the tragic death of Martha Mills, whose family repeatedly raised concerns about her condition before she died in hospital. The subsequent campaign highlighted the importance of ensuring that patients and those closest to them have a clear route to request an independent clinical review when they feel that deterioration is not being recognised or responded to appropriately.

What many people may not realise is that in our organisation, an acute NHS provider, this principle is not new. For the past six years, we have operated a service based on the same concept. Before being aligned with the national Martha's Rule programme, it was known locally as Call for Concern.

For many years, the service worked exactly as intended. It typically received between five and ten calls each month. Most callers were family members, carers or friends who were genuinely worried that their loved one's condition was worsening or who felt that important aspects of care were not progressing as expected. The service provided a valuable safety net, enabling concerns to be heard and reviewed by experienced clinicians when required.

Call for Concern was seen as a positive addition to patient safety. It helped strengthen communication between staff and families, provided reassurance when concerns were unfounded and, occasionally, identified situations where further clinical review was needed. It was a practical example of listening to patients and those who know them best.

The changing nature of the calls

However, since the widespread promotion of Martha's Rule through national media coverage and high-profile campaigning, where I work we have experienced a significant increase in demand. Greater awareness of the service is, in many respects, a positive outcome. More people know that support is available and that their concerns can be escalated if necessary. Our organisation has responded by increasing capacity to ensure that the service can continue to operate safely and effectively.

What has been more challenging is the changing nature of the calls being received.

Historically, calls were largely focused on concerns about clinical deterioration. Increasingly, however, the service is receiving calls relating to dissatisfaction with waiting times, frustrations about communication, requests to be seen more quickly or general complaints about care. While these concerns are often genuine and understandable, they are not always within the intended scope of Martha's Rule.

Alongside this shift, staff have reported a rise in aggressive and abusive behaviour from some callers. Clinical outreach teams answering these calls are often confronted by individuals who are distressed, frustrated and seeking immediate solutions. Despite staff making every effort to listen, support and direct callers to the most appropriate route, conversations can quickly become difficult when expectations cannot be met. Staff have also reported occasions where conversations have been recorded without their knowledge or consent, adding to feelings of vulnerability among professionals who are often attempting to support families in highly emotive circumstances.

While families and carers are frequently acting from a place of anxiety, uncertainty and concern for a loved one, organisations must also consider the impact that these interactions can have on staff wellbeing and psychological safety.

A difficult balance

A further challenge is that there is often no practical mechanism for staff receiving these calls to deliver the outcome being requested. The outreach team cannot bypass existing clinical priorities, create additional resources or instruct teams to see patients ahead of others who may have a greater clinical need. Our role is to assess concerns about deterioration and facilitate appropriate review, not to alter operational pressures within the wider healthcare system.

This is particularly difficult during out-of-hours periods. At 2am, for example, there may be very limited options available beyond ensuring that concerns have been appropriately assessed and communicated to the responsible clinical team. There is often no alternative service to which callers can be redirected for a quicker response. When families are worried and feel they have exhausted all other avenues, hearing that there is no immediate solution can understandably increase their frustration. Unfortunately, this frustration is sometimes directed at the very staff trying to help them.

The challenge is compounded by the perception that Martha's Rule can resolve issues that would traditionally be addressed through complaints or patient experience processes. However, while these systems exist for good reason, they are not designed to provide immediate answers during an active hospital admission. For families seeking urgent reassurance, the complaints process can feel too slow, leading them to view Martha's Rule as the only available route to escalate concerns.

This creates a difficult balance. On one hand, nobody would wish to discourage patients and families from speaking up when they believe a loved one is deteriorating. On the other, if the service becomes overwhelmed by issues unrelated to deterioration, there is a risk that its core patient safety function could be diluted.

Opportunities to learn

The experience within our organisation highlights an important learning opportunity as Martha's Rule continues to expand nationally. Raising awareness is essential, but so too is helping patients and families understand the purpose of the service and what it can realistically achieve. Equally important is ensuring that there are responsive and accessible routes for concerns that do not relate to clinical deterioration.

This learning is particularly timely given the recent announcement that Martha's Rule will be expanded to all Accident and Emergency departments across England through a phased national rollout due to be completed by March 2028.[1] The expansion will enable patients, families, carers and staff within emergency departments to request an urgent review if they are concerned that a patient's condition is deteriorating and their concerns are not being heard. While this represents an important step forward for patient safety, it also highlights the need to support staff who receive and respond to these calls, particularly in high-pressure environments where difficult conversations are common.

Ensuring that patients and families feel empowered to raise concerns must sit alongside efforts to promote respectful communication, realistic expectations and psychological safety for healthcare professionals.

Martha's Rule remains a valuable patient safety initiative and an important safeguard for patients and families. The challenge now is not whether the service is needed, but how healthcare organisations can preserve its original purpose while managing the increased expectations that have accompanied its growing profile.

If we are to protect what makes Martha's Rule so effective, we must ensure that it remains focused on what it was designed to do: providing an urgent escalation route when there are genuine concerns that a patient's condition is deteriorating, while supporting the staff who work every day to make that possible.

Reference

1. NHS England. Implementation of Martha’s Rule in emergency departments. 21 September 2026.

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We would love to hear your thoughts on this blog.:

• How is your organisation implementing Martha's Rule?

• How are you communicating it to patients and families

• What challenges are you facing?

• What have you learnt?

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About the author

A critical care outreach nurse in an acute NHS Trust.