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Showing results for tags 'Deterioration'.
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Content Article
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In December 2022 Dylan Cope, a 9 year old boy, died of sepsis after being discharged from hospital. A coroner found the boy's death “would have been avoided if he had not been erroneously discharged”, and said what happened "amounts to a gross failure of basic care”. This guidance has been developed by Dylan's mum Corinne Cope, following her lived experience as a bereaved mother. Corinne says: "Multiple investigations failed to provide clear answers or accountability, causing significant secondary harm; an issue increasingly recognised among harmed patients, bereaved families, and healthcare staff." Corinne's guidance aims to support NHS investigators and system leaders to strengthen the quality and humanity of investigations, ensuring ownership, reflection, and sustained learning. -
News ArticleFor six awful days last summer, as her father, David, got progressively sicker in the cardiac ward of the John Radcliffe hospital in Oxford, Karen Osenton would read the poster above his bed telling patients about their right under Martha’s rule to ask for a second opinion. Her father, a retired engineer in his early 70s who was normally extremely fit, was by then thin, jaundiced and could barely lift his head from the pillow. David had first gone to his GP more than a month earlier complaining of extreme breathlessness, and over the following weeks he had become increasingly thin and weak with suspected heart failure. But it had taken repeated visits to the accident and emergency ward, being sent home each time, before he was finally given a bed in a specialist cardiac unit last July. “Every day we saw him he got worse,” says Karen, a teacher from Aynho, in West Northamptonshire. “My mum kept saying: ‘Please, my husband is not right, this is not David. He is so unbelievably poorly.’ He couldn’t walk, he didn’t sleep, he couldn’t eat. Even the other gentlemen in the bay were saying to the nurses: ‘Can you not see this man is extremely unwell?’” “He was on the edge of the bed, rocking, and he could barely speak. He was so yellow, so gaunt. I just walked to the desk and I said: ‘You will get a consultant here now. I am invoking Martha’s rule. I want somebody to see my dad right now.’” Within minutes, says his daughter, the room was full of doctors. “He was very close to death. His lungs were filled with fluid. He had multi-organ failure. Within the hour he was in intensive care, fighting for his life.” A senior consultant told Karen her father was “the sickest person in the hospital”. Oxford University Hospitals NHS foundation trust (OUH), which oversees the hospital, has apologised to the family and admitted it made mistakes in treating David’s cardiac failure. While some of the delays in assessing him were “unfortunately due to service pressures and staffing limitations”, the hospital said after a review of his case, clinicians also failed to spot that he was getting worse, and by the time they did, he was too unwell to have the recommended surgical valve repair. In addition, a “lapse in communication” meant there was confusion between two different teams over which was responsible for his care. Read full story Source: The Guardian, 1 May 2026 Further reading on the hub: The formative evaluation of the implementation of Martha’s Rule: Interim Report (NIHR Policy Research Unit, March 2026) Embedding Martha's Rule into practice—Lessons from the national pilot Martha's Rule - Merope Mills (Martha’s mother) explains Martha’s story (31 March 2026
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News ArticleMore than 500 people have received potentially life-saving care thanks to Martha’s rule, which gives hospital patients the right to seek a second opinion about their health. They were moved to intensive care or a specialist unit after they, a loved one or a member of NHS staff triggered the patient safety mechanism, which the NHS in England began using in 2024. Martha’s rule lets patients, relatives and staff call a helpline run by the hospital if they are worried about the person’s condition or treatment and ask for a “rapid review” of their care. In the 18 months between September 2024 and February 2026, a total of 524 adults and children about whom concerns had been raised were moved to an intensive care or high-dependency unit, a specialist hospital or a specialist ward at the hospital where they were already an inpatient. Wes Streeting, the health secretary, said the figures proved that Martha’s rule is “already having a life-saving impact”. It has been widely hailed as a major advance in patient safety. Martha’s rule is named after Martha Mills, who died aged 13 in 2021 after her family’s concerns that she was deteriorating went unheeded by staff at King’s College hospital in London. NHS England’s latest data on how Martha’s rule is operating shows that 12,301 calls were made to Martha’s rule helplines during those 18 months. About one in three – 4,047 – helped to identify a patient whose health was getting worse. Three-quarters of them (2,967) were made either by a patient and their carer or by the patient themselves. Hospital staff made the other 1,080. Read full story Source: The Guardian, 1 May 2026 Further reading on the hub: Embedding Martha's Rule into practice—Lessons from the national pilot Martha's Rule - Merope Mills (Martha’s mother) explains Martha’s story (31 March 2026
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Content ArticleIn June 2024, Martha’s Rule was introduced into 143 NHS Trusts. This rule allows patients, families and staff to quickly request an urgent review from an independent medical team if they’re worried a patient is worsening and feel their concerns aren’t being heard. It also requires hospitals to regularly check in with patients and families about how the patient is doing. This interim report presents findings from an independent evaluation of Martha's Rule carried out between November 2024 and February 2026. This was undertaken by the patient safety arm of the National Institute for Health and Care Research (NIHR) Policy Research Unit in Quality, Safety and Outcomes for Health and Social Care to understand how the first rollout of Martha’s Rule is working for patients, families and healthcare staff. It draws on a prospective in depth case study across three hospital trust pilot sites, involving observations, interviews and documentary analysis, accompanied by a systematic review of literature and a public awareness survey, which was conducted in collaboration with Picker. Key learning points highlighted by this report include: To date, one in three people (public, patient and family) are aware of Martha's Rule, and some minoritised groups face additional barriers to understanding. Patients, families, and staff value Martha's Rule for its ability to amplify their voices, facilitate open communication, promote collaborative care and improve escalation pathway between ward and critical care outreach teams. Patients and families lack clear information about the purpose of the structured wellness question and its role in their care. There is variation in the way in which the wellness question is being operationalised, with a shift to informal ways of asking and inconsistencies in recording patient and family voice. Awareness appears limited amongst some staff groups, particularly medical and specialist teams and transient staff. Callers to the helpline are seeking clearer information about ongoing care and support after escalating concerns. There may be barriers for some groups - those most in need may be least able to access Martha's Rule; these are not limited to those with protected characteristics. Not all trusts/wards/teams are 'equal' - differences in responding team (critical care outreach) and ward cultures (and priorities), as well as staff attitudes and delivery models, can influence the adoption of Martha's Rule and ultimately, patient, family and staff involvement in the identification of deterioration. Implementation has placed additional demands on critical care outreach staff, who are routinely tasked with managing escalations of deteriorating patients. This has raised concerns about responding to general concerns via the helpline leading to emotional burden, delayed responses and potential compromises in care for other critically ill patients. Related reading Embedding Martha's Rule into practice—Lessons from the national pilot Martha's Rule - Merope Mills (Martha’s mother) explains Martha’s story (31 March 2026) Martha's Rule: Jo and Anna share their patient experience of Martha’s Rule (NHS England, 31 March 2026)
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Content ArticleSepsis, life-threatening acute organ dysfunction due to infection, is a global health priorit with approximately 49 million cases and 13 million sepsis-related deaths each year. Beyond being acutely deadly, sepsis contributes to new and worsened physical, cognitive, and mental health problems in many survivors. Early identification and treatment are critical to improving outcomes. The Surviving Sepsis Campaign (SSC) guidelines are intended to support clinicians caring for adult patients with sepsis, focusing on management in the hospital, the immediate prehospital setting, and the immediate post-hospital setting. These guidelines incorporate principles of antimicrobial stewardship through responsible antimicrobial use, proper diagnostic strategies, and de-escalation of antimicrobial therapy. The recommendations reflect evidence-based best practice, distilling a large body of research into actionable recommendations. They empower individuals and health systems to make informed choices about care and support improvements in management and outcomes of sepsis. Further reading on the hub: Spotting the signs of sepsis: a series of short videos Top picks: 13 resources about sepsis
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Content ArticleMartha’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 a patient’s condition is getting worse and their concerns are not being responded to. In this video, Dr Ronnie Cheung, consultant paediatrician, shares his experience of Martha’s Rule.
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Content ArticleMartha’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 a patient’s condition is getting worse and their concerns are not being responded to. In this video, Martha's mother explains Martha's story.
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Content ArticleMartha’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 a patient’s condition is getting worse and their concerns are not being responded to. In this video, nurses Jo and Anna share their patient experience of Martha’s Rule.
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Content Article
hub topic lead Richard Jones highlights an incident where the sepsis warning AI system failed to highlight a patient's deterioration and led to an avoidable death. I'll hide the location of this tragic story. A busy nurse was doing her evening rounds. The ward was short on staff and so the nurse took some observations and put them on her uniform as a Post-It note. She'd enter the data later. The patient had cancer and was heavily immunocompromised. The nurse got back around to the patient and took further observations. She then went to enter them in the system. The AI in the system had been trained to understand that two observations so close (in time) was an issue and so it ignored one. This meant it did not enter the details of the patient's vitals that showed the patient had an issue (sepsis). The patient was given an Amber alert status instead of a Red one. The next day the patient died. The nurse was not at fault. You could argue the system was not at fault. However, it lacked 'real-world' experience of how nurses operate. The learning point here? I'm not sure. Mindless reliance on systems to spot the things we miss is unhelpful but I have never regretted a conversation with a nurse regarding how they work and how they care. -
EventThis conference focuses on recognising & responding to the deteriorating patient in paediatrics and ensuring best practice in the use of the National Paediatric Early Warning System. The conference will include National Developments including effective implementation of PEWS in inpatient and emergency departments, Marthas Rule in Paediatrics and will update you on the November 2025 Suspected sepsis in under 16s: recognition, diagnosis and early management. The conference will include practical case study based sessions on identifying children at risk of deterioration, improving practice in PEWS, the role of human factors in responding to the deteriorating child, understanding success factors in escalation, and improving the involvement of parents, families and children themselves in in recognising deterioration. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/deterioration-in-paediatrics or email [email protected] hub members get at 20% discount. Email [email protected] for discount code.
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Content Article
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Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. Early recognition and treatment are vital to save lives. This series of short videos (each under two minutes), produced by Patient Safety Learning in collaboration with The UK Sepsis Trust, aims to raise awareness of the key signs and symptoms of sepsis. Featuring Dr Ron Daniels, Founder and Chief Medical Officer of The UK Sepsis Trust and Topic Leader for the hub, these videos outline what to look out for across different age groups. Videos include: Spotting the signs of sepsis in adults and young people (1 minute) Spotting the signs of sepsis in school-aged children (90 seconds) Spotting the signs of sepsis in children under five years old (2 minutes) Related content Please also see our other video in this series: Sepsis risks in rural communities -
Content Article
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Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. Early recognition and treatment are vital to save lives. This 5 minute video, produced by Patient Safety Learning in collaboration with The UK Sepsis Trust, explains the sepsis risks that need to be considered in rural communities. Featuring Dr Ron Daniels, Founder and Chief Medical Officer of The UK Sepsis Trust and Topic Leader for the hub, we look at: The factors that affect rural communities. How these can impact sepsis outcomes. What healthcare professionals can do to support good outcomes. What support there is for healthcare professionals. This is part of our wider sepsis awareness series which includes a series of short videos on spotting the signs of sepsis in adults and children. Related content: -
Content ArticleThe Australian Commission has released four new resources to help health services address gaps and inconsistencies in care coordination and post-sepsis support for survivors, families, carers and those bereaved by sepsis. Developed for the Australian Commission as part of the National Sepsis Program, these resources aim to improve care delivery and ensure patients receive consistent, high-quality support throughout the sepsis journey. These resources include: Model of Care Framework – outlining the essential elements for effective sepsis care and follow-up support Business case – supporting investment in coordinated care and post-sepsis services Supporting information and implementation companion report – offering practical steps for applying the framework in different healthcare settings. An interactive tool has also been developed to help health services explore how these elements can be adapted for local settings. These resources align closely with the Sepsis Clinical Care Standard and particularly support the implementation Quality Statements 4 to 7.
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Content ArticlePatients admitted via Emergency Departments (EDs) sustain twice as many in-hospital adverse events than non-emergency admissions. Unwarranted variation in care, that is, differences not explained by patient illness, care needs, or patient preferences, contributes to adverse patient outcomes. The HIRAID® framework [History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, reassessment, and communication], standardises nursing assessment and management of patients in the ED. The aim of this study was to test the effect of HIRAID® on the quality and safety of emergency care. It found that emergency nurses' use of HIRAID® significantly reduced inpatient deterioration requiring a rapid response team call and improved patient experience and perceived quality of clinical handover.
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Content ArticleIn this interview, Dana Edelson, an expert in cardiac resuscitation at the University of Chicago, discusses how hospitals can best use early warning score tools to risk stratify patients—without adding to clinicians’ alarm fatigue. Dana recently co-authored a study which compared six different early warning scores designed to recognise clinical deterioration in hospitalised patients, including three proprietary AI tools.
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Content ArticleThis cohort study examined how hospital six early warning scores compare with one another, based on 362,926 patient encounters. The authors compared three proprietary artificial intelligence (AI) early warning scores: Simultaneous Epic Deterioration Index (EDI) Rothman Index (RI) eCARTv5 (eCART) against three publicly available simple aggregated weighted scores: Modified Early Warning Score (MEWS) National Early Warning Score (NEWS) NEWS2 scores. In the study, eCART outperformed the other AI and non-AI scores, identifying more deteriorating patients with fewer false alarms and sufficient time to intervene. NEWS, a non-AI, publicly available early warning score, significantly outperformed EDI. The authors concluded that, given the wide variation in accuracy, additional transparency and oversight of early warning tools may be warranted.
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Content ArticleMedical Care are joined by Dr Marisa Mason, chief executive of NCEPOD, and Dr Alison Tavare, GP, primary care clinical lead at Health Innovation West of England, and clinical coordinator as NCEPOD, as part of their ‘navigating patient safety’ series. In this session, they explore how NCEPOD's work has driven vital patient safety initiatives, including national early warning scores and the management of sepsis.
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Content ArticleThe number of sepsis-related inpatient stays at non-federal acute care hospitals in the United States increased from 1.8 million in 2016 to 2.5 million in 2021, with a faster rate of increase following the emergence of Covid-19 in 2020, according to an Agency for Healthcare Research and Quality (AHRQ) report to Congress. AHRQ’s comprehensive federal analysis includes detailed information on national trends in hospital utilisation, morbidity, and in-hospital mortality; trends for key patient populations; disparities in hospital utilization for sepsis and associated outcomes; and state variations in hospital utilization and associated costs, and in-hospital mortality rates.
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Content ArticleSepsis Research FEAT and the James Lind Alliance have identified the top ten research priorities that will shape the future of sepsis treatment and care, with the goal of saving tens of thousands of lives each year. The Sepsis Priority Setting Partnership, which brought together over 1700 participants - including sepsis survivors, their families, carers and healthcare professionals - has delivered a guide for future research. 10 research questions highlight the next key areas which require funding and investigation to ensure meaningful progress in sepsis diagnosis, treatment, and recovery. The top ten questions for research are as follows: 1. How can the diagnosis of sepsis become faster, more accurate and reliable? 2. What are the long-term effects on the body from sepsis (sometimes called post-sepsis syndrome)? How are these long-term effects best treated and managed? 3. What is the role of treatments other than antibiotics in the care and management of sepsis? 4. Can diagnostic tests be developed for sepsis that can be used wherever the person is receiving care (e.g. in a GP surgery, hospital, ambulance or at home)? 5. Why and how do some people with sepsis become seriously ill very quickly? 6. Would specialist sepsis services improve outcomes for people with sepsis during hospital treatment and for follow-up care? 7. Are there ways to tailor treatment of sepsis to the individual (e.g. based on blood markers or other indicators)? 8. How does an infection lead to sepsis? 9. Would treatment before admission to hospital (e.g. provided by GPs or ambulance crews) improve outcomes for people with sepsis? 10. What are the safest and most effective ways to treat sepsis using antibiotics?
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News Article
Nationwide roll out of AI tool that predicts falls and viruses
Patient Safety Learning posted a news article in News
An AI tool is being rolled out across the NHS that can predict a patient’s risk of falling with 97% accuracy, preventing up to 2,000 falls and hospital admissions each day. The predictive tool, developed by Cera, is being used in more than two million patient home care visits a month, monitoring vital health signs such as blood pressure, heart rate and temperature, to predict signs of deterioration in advance so it can then alert healthcare staff. It is in use across more than two-thirds of NHS integrated care systems and helps to provide care at home by flagging up to 5,000 high-risk alerts a day, reducing hospitalisations by up to 70%. Dr Vin Diwakar, national director of transformation at NHS England, said: “This new tool now being used across the country shows how the NHS is harnessing the latest technology, including AI, to not only improve the care patients receive but also to boost efficiency across the NHS by cutting unnecessary admissions and freeing up beds ahead of next winter, helping hospitals to mitigate typical seasonal pressures. “We know falls are the leading cause of hospital admissions in older people, causing untold suffering, affecting millions each year and costing the NHS around £2 billion, so this new software has the potential to be a real game-changer in the way we can predict, prevent and treat people in the community. “This AI tool is a perfect example of how the NHS can use the latest tech to keep more patients safe at home and out of hospital, two cornerstones of the upcoming 10-year Health Plan that will see shifts from analogue to digital, and from hospital to community care.” The software will also be used to detect the symptoms of winter illnesses like Covid, flu, RSV, and norovirus, allowing NHS and care teams to intervene before hospital care is needed. Read full story Source: Digital Health, 5 March 2025 -
EventThis conference focuses on recognising and responding to the deteriorating patient in primary and community care. The conference will include National Developments including the new Sepsis 2024 NICE guidance, the national rollout of Martha’s Rule, and focus on best practice in primary care. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in primary care, the community including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/deteriorating-patient-summit=primary-care or email [email protected] Follow on Twitter @HCUK_Clare #DeterioratingPatient hub members get a 20% discount. Email [email protected] for discount code.
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EventThis conference focuses on recognising and responding to the deteriorating patient in primary and community care. The conference will include National Developments including the new Sepsis 2024 NICE guidance, the national rollout of Martha’s Rule, and focus on best practice in primary care. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in primary care, the community including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit=primary-care or email [email protected] Follow on Twitter @HCUK_Clare #DeterioratingPatient hub members receive a 20% discount. Email [email protected] for discount code.
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EventuntilThere are very few routine and reliable mechanisms for patients, carers and families to escalate past the primary team when concerned about standard care not meeting their needs. Failing to escalate in a timely manner timely can have adverse effects to patient outcomes. It has been recognised that having reliable patient and family escalation systems is also a quality marker of patient centred care. NHS England’s Worry and Concern Task and Finish Group (a subgroup of the Acute Deterioration Board) have run a national improvement collaborative from April 2023 for 12 months. Bradford Teaching Hospitals NHS Foundation Trust has participated in this pilot to develop, test, implement and evaluate methods to incorporate patients’ views of their wellness/illness and worries and concerns in the assessment and recognition of acute illness and risk of deterioration. Register
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EventThis conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. The Recording of NEWS2 score, escalation time and response time for unplanned critical care admissions is now an NHS CQUIN goal. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/deteriorating-patient-summit or email [email protected]. hub members receive a 20% discount. Email [email protected] for the discount code. Follow on Twitter @HCUK_Clare #DeterioratingPatient
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EventIn the dynamic landscape of healthcare, the unexpected deterioration of a hospital patient can present daunting challenges for both medical professionals and families alike. It is during these critical moments that the significance of patient rescue becomes abundantly clear. From the perspective of physicians, nurses, and other healthcare providers, swift and effective intervention is imperative to ensure the best possible outcome. However, the role of the patient's family in such situations is equally crucial. Empowered with knowledge and equipped with effective communication strategies, families can play a pivotal role in advocating for their loved ones and contributing to the overall success of rescue efforts. The World Patients Alliance is pleased to organise a webinar titled “The Deteriorating Patient: When a hospital patient unexpectedly goes downhill, what can families do?" Join the webinar and delve into the importance of patient rescue from the physician's perspective, explore real-life patient stories, introduce Martha's Rule as a guiding principle, analyse the current state of rapid response protocols, and discuss the critical role of families in effectively communicating concerns. Register
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