Martha’s Rule is a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon.
It has been developed in response to the death of Martha Mills and other cases related to the management of deterioration. Central to Martha’s Rule is the right for patients, families and carers to request a rapid review if they are worried that their own or their loved one’s condition is getting worse and their concerns are not being responded to.
The Royal Manchester Children's Hospital's (RMCH) was one of the pilot sites during the first year of the Martha's Rule pilot. This blog outlines the hospital's efforts over the past year to integrate Martha’s Rule into everyday clinical practice, aiming to empower staff and families to raise concerns effectively on patient deterioration.
Embedding Martha's Rule into practice: Lessons from our pilot
Over the past year, our focus has been on embedding the components of Martha's Rule (MR) into everyday clinical practice—ensuring that staff across all levels understand their role in the process and feel equipped to respond effectively to concerns raised by patients and families.
Tailored education for diverse staff groups
One of our earliest challenges was designing education that resonated with different staff roles. We recognised that ward nurses, medics and other clinical teams needed training that reflected their specific responsibilities within the MR pathway. Initially, we concentrated on face-to-face sessions supported by PowerPoint presentations. These laid the groundwork for understanding MR, but we knew we needed something more scalable. That’s why we developed an e-learning package, which is now live on our hospital's e-learning hub and is included in staff mandatory training. The e-learning package is structured to provide appropriate awareness within individual staff groups, ensuring consistent understanding of deterioration across the board.
Using data to drive safety and insight
From a data perspective, we explored how to assess the safety of our current system and identify what information we needed to monitor effectiveness. We examined numerical indicators such as:
deterioration rates
cardiac arrest calls
admissions to paediatric critical care.
In addition, we collected qualitative data around complaints and incidents—especially those involving parental concerns.
We triangulated these data sources to build a clearer picture of where improvements were needed. Although much of this analysis has been internal, we’ve begun integrating elements into the HIVE system (our electronic patient record system), to create dashboard-style visibility. We’ve also developed a dedicated database to track MR calls, allowing us to identify themes and trends by team, location, age, ethnicity and, potentially, deprivation.
Listening to families: A crucial voice
Although patient groups weren’t directly involved in shaping the e-learning package, we did engage with families during the early stages of the MR pilot. Their feedback was invaluable. Many expressed frustrations about unanswered queries and feeling left in limbo and feeling disempowered by a lack of cohesive response. These insights helped us reinforce key messages in the training, particularly around how concerns are acknowledged and escalated.
Looking back, we recognise that capturing family feedback earlier would have strengthened the process. We’re now addressing ongoing challenges, especially for families whose first language isn’t English. While many preferred phone communication, we’ve taken steps to improve accessibility.
Expanding access and inclusion
We’ve created a multilingual space on the MR site, allowing users to select their preferred language. To bridge the gap between ward posters and digital resources, we have added QR codes that link directly to the site. This will include contact details for the MR team and background information about the initiative. It’s a tangible outcome of the pilot and a testament to how much we’ve learned along the way.
What happens after a call?
Encouragingly, families have reported that their concerns are being responded to once MR calls are made. We’re also mindful not to interpret low call volumes as a sign that everything is fine. That’s why we continue to monitor all sources of information, ensuring we’re not missing signs of deterioration.
From pilot wards, we haven’t seen incidents or complaints that suggest missed cases, nor admissions to critical care that raise red flags. But vigilance remains key.
What’s next?
The e-learning package will be rolled out beyond pilot wards, ready for a hospital-wide rollout in mid-October 2025, ensuring widespread access and training before full expansion. MR principles are now embedded in induction for new nursing staff and resident doctors, reinforcing our commitment to making MR a core part of our culture.
What has your experience been in implementing Martha's Rule?
We'd welcome more experiences of implementing Martha's Rule we can share on the hub. What were the challenges? What worked well?
You can share your with us by commenting below (sign up here for free first), or submitting a blog, or by emailing us at
[email protected].
Martha’s Rule is a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon. It has been developed in response to the death of Martha Mills and other cases related to the management of deterioration. Central to Martha’s Rule is the right for patients, families and carers to request a rapid review if they are worried that their own or their loved one’s condition is getting worse and their concerns are not being responded to. The Royal Manchester Children's Hospital's (RMCH) was one of the pilot sites during the first year of the Martha's Rule pilot. This blog outlines the hospital's efforts over the past year to integrate Martha’s Rule into everyday clinical practice, aiming to empower staff and families to raise concerns effectively on patient deterioration. Embedding Martha's Rule into practice: Lessons from our pilot Over the past year, our focus has been on embedding the components of Martha's Rule (MR) into everyday clinical practice—ensuring that staff across all levels understand their role in the process and feel equipped to respond effectively to concerns raised by patients and families. Tailored education for diverse staff groups One of our earliest challenges was designing education that resonated with different staff roles. We recognised that ward nurses, medics and other clinical teams needed training that reflected their specific responsibilities within the MR pathway. Initially, we concentrated on face-to-face sessions supported by PowerPoint presentations. These laid the groundwork for understanding MR, but we knew we needed something more scalable. That’s why we developed an e-learning package, which is now live on our hospital's e-learning hub and is included in staff mandatory training. The e-learning package is structured to provide appropriate awareness within individual staff groups, ensuring consistent understanding of deterioration across the board. Using data to drive safety and insight From a data perspective, we explored how to assess the safety of our current system and identify what information we needed to monitor effectiveness. We examined numerical indicators such as: deterioration rates cardiac arrest calls admissions to paediatric critical care. In addition, we collected qualitative data around complaints and incidents—especially those involving parental concerns. We triangulated these data sources to build a clearer picture of where improvements were needed. Although much of this analysis has been internal, we’ve begun integrating elements into the HIVE system (our electronic patient record system), to create dashboard-style visibility. We’ve also developed a dedicated database to track MR calls, allowing us to identify themes and trends by team, location, age, ethnicity and, potentially, deprivation. Listening to families: A crucial voice Although patient groups weren’t directly involved in shaping the e-learning package, we did engage with families during the early stages of the MR pilot. Their feedback was invaluable. Many expressed frustrations about unanswered queries and feeling left in limbo and feeling disempowered by a lack of cohesive response. These insights helped us reinforce key messages in the training, particularly around how concerns are acknowledged and escalated. Looking back, we recognise that capturing family feedback earlier would have strengthened the process. We’re now addressing ongoing challenges, especially for families whose first language isn’t English. While many preferred phone communication, we’ve taken steps to improve accessibility. Expanding access and inclusion We’ve created a multilingual space on the MR site, allowing users to select their preferred language. To bridge the gap between ward posters and digital resources, we have added QR codes that link directly to the site. This will include contact details for the MR team and background information about the initiative. It’s a tangible outcome of the pilot and a testament to how much we’ve learned along the way. What happens after a call? Encouragingly, families have reported that their concerns are being responded to once MR calls are made. We’re also mindful not to interpret low call volumes as a sign that everything is fine. That’s why we continue to monitor all sources of information, ensuring we’re not missing signs of deterioration. From pilot wards, we haven’t seen incidents or complaints that suggest missed cases, nor admissions to critical care that raise red flags. But vigilance remains key. What’s next? The e-learning package will be rolled out beyond pilot wards, ready for a hospital-wide rollout in mid-October 2025, ensuring widespread access and training before full expansion. MR principles are now embedded in induction for new nursing staff and resident doctors, reinforcing our commitment to making MR a core part of our culture. What has your experience been in implementing Martha's Rule? We'd welcome more experiences of implementing Martha's Rule we can share on the hub. What were the challenges? What worked well? You can share your with us by commenting below (sign up here for free first), or submitting a blog, or by emailing us at [email protected].
