Martha's Rule is a national patient safety initiative that gives patients, families, carers and NHS staff a clear way to ask for an urgent review when they are worried that a patient's condition is getting worse and their concerns are not being listened to and acted on. This rule has been developed in response to the death of Martha Mills and other similar cases where a central issue has been the importance of patients, families and carers to request a rapid review if they are concerned about a patient’s condition getting worse. NHS Trusts are now working to put this in place in all acute in patient settings.

For patients and/or their families who later have concerns about possible medical negligence, the Rule may also be relevant to the evidence related to their treatment. For example if there is a record of concerns, escalation calls, observations and reviews, this documents that these concerns were raised and should provide evidence as to the response to such concerns when you reported your symptoms and crucially how the hospital responded. 

However, it is important to be aware that the basis of clinical negligence cases does not change and raising concerns under Martha's Rule does not itself prove medical negligence. Additionally you do not need to have raised such concerns to make a claim.

What is Martha's Rule in the NHS?

Martha's Rule is a patient safety initiative created by NHS England to identify and manage deterioration in people receiving hospital care. It is designed to make sure the concerns of patients, families, carers and staff are listened to and acted on when someone may be becoming more unwell.

It has three core components:

• Patients are asked how they are feeling: staff should ask patients, at least daily, whether they feel better or worse and record this information in a structured way.
• NHS staff can escalate concerns: a doctor, nurse or other member of the healthcare team who is worried about an inpatient's condition can ask for a review by a different team.
• Patients, families and carers can request a rapid review: if they are concerned that a patient's condition is deteriorating and feel their concerns are not being heard, they can use a dedicated escalation route to request an urgent review.

Martha's Rule recognises that patients recovering in hospital, and the people close to them, may notice small or unexpected signs before they show up in routine measurements. These can be early warning signs of deterioration, so the patient's and family's observations should form part of the hospital's response.

Why was Martha's Rule introduced?

Martha Mills sadly died aged 13 in 2021 after developing sepsis while being treated in a hospital. She had been admitted with a pancreatic injury after falling off her bike.

Martha's family's concerns about her deteriorating condition were not responded to as they should have been. At the inquest, the coroner ruled that Martha would probably have survived if she had been moved to intensive care earlier and appropriately treated. The coroner's Prevention of Future Deaths report also identified a failure to refer her promptly to paediatric intensive care.

In September 2023, Martha's mother, Merope Mills, and her father, Paul Laity, then campaigned for a clear route allowing patients and families to escalate vitally important concerns about deterioration. Martha's family's concerns, and the wider questions raised by her care, became the basis for a national approach focused on improving patient safety.

How has Martha's Rule developed?

Within weeks of the publicity campaign getting underway, the government had committed to introducing Martha’s Rule in England. NHS England announced the national programme in February 2024, and 143 hospital sites took part in the first phase. By September 2025, the Rule had been rolled out to all 210 acute inpatient sites in England, although hospitals were at different stages of putting it in place. 

The NHS Standard Contract now requires NHS trusts and NHS foundation trusts to implement its three core components by 31 March 2027, and the programme is being extended to maternity, neonatal and A&E services.

What rights does Martha's Rule give patients and families?

Martha's Rule gives patients, families, carers and medical staff a formal route to request an urgent clinical review when they believe an inpatient's condition is getting worse and their concerns have not been adequately addressed by the immediate care team.

In practice, it means:

• Concerns about deterioration can be escalated through a defined process
• A patient, family member, carer or medical staff can request review by a different team
• The escalation service should be available 24 hours a day, seven days a week where the Rule is operating
• Patients should be asked regularly whether they feel better or worse
• Doctors, nurses and other staff also have a route to escalate clinical concerns

These protections are important because a patient, parent, partner or carer may notice changes that are not immediately apparent to the ward team.

Is Martha's Rule a law?

No. Although some people have referred to the Rule as "Martha's Law", the official name is Martha's Rule and it is not a standalone Act of Parliament.

It is an NHS patient safety framework. The NHS Standard Contract 2026/27 requires NHS trusts and NHS foundation trusts to implement its three core components by 31 March 2027. That is different from creating a separate statutory legal right or a new type of medical negligence claim.

The Rule does, however, provide an established route to ask for a rapid review within services where it has been implemented.

How do you use Martha's Rule?

If you are worried that an inpatient's condition is getting worse, tell the doctor, ward nurse or nurse in charge what has changed and why you are concerned.

If you remain worried and feel the care team is not fully responding, ask how to use Martha's Rule. The local process will usually involve:

1. Raising the concern with the immediate care team: explain the changes you have noticed.
2. Requesting a review if the concern remains unresolved: look for Martha's Rule posters, ask hospital staff or check the hospital website for the local contact route.
3. Explaining what is happening: you may be asked for the patient's name, ward or location, your relationship to them and a brief description of the concern.
4. A review by a different team: if you are concerned a patient is deteriorating and concerns are not being acted upon. Depending on the hospital, this may be a critical care outreach team or another team experienced in assessing very unwell patients. They may give advice over the phone, visit the ward to assess the patient, or both. 

For example, a family member may notice that an inpatient is becoming unusually drowsy, confused or more short of breath and feel that the change has not been fully recognised. The Rule gives them a route to ask for an urgent review rather than simply repeating the same concern without escalation.

Is there a Martha's Rule phone number?

There is no single national number. Each hospital has its own dedicated phone number or local escalation route.

National guidance advises patients and families to check the hospital website, look for posters or ask hospital staff for the correct contact details.

Some hospitals may use an existing service called Call 4 Concern or a similar local concern service. These types of services pre-date the national initiative in some trusts and provide a route for patients and families to raise concerns about deterioration.

What happens after you use Martha's Rule?

Martha’s Rule encourages patients, families and carers to tell staff if they are worried a health condition is getting worse. This should be acted on in a structured way and there is extensive work being progressed to implement and train staff on this approach. If after speaking to the care team, you remain worried, a patient, family member, carer or member of staff can call a dedicated number for rapid review. The call should be picked up by a different team from the one providing the patient's immediate care. In many acute hospitals, this is a critical care outreach team or another team experienced in assessing deterioration and possible critical illness. Depending on the hospital and the concern, the team may give advice over the phone, come to the ward to assess the patient, or both. 

The reviewing team can assess the patient, speak to the doctors and nurses providing care, consider the concerns raised and decide whether further action is needed. That might include additional monitoring, investigations, treatment changes, specialist referral or transfer to a higher level of care such as intensive care.

The review may also conclude that the existing care plan remains appropriate. The Rule therefore gives access to an urgent review, but does not guarantee a particular diagnosis, treatment or transfer.

What is the difference between Martha's Rule and a second opinion?

The difference between Martha's Rule and a second opinion is mainly the reason for seeking another clinical view and how urgently it is needed. Martha's Rule and second-opinion requests can both involve another healthcare professional, but they are designed for different situations.

• Martha's Rule is for urgent concerns about deterioration. If a patient's condition is getting worse and the patient, family or carer feels their concerns are not being listened to and acted on, they can use Martha's Rule to request a rapid review. The review is carried out through the hospital's escalation process, often by a critical care outreach team or another team experienced in assessing very unwell or critically ill patients. In this context, Martha's Rule is a patient safety service designed to recognise and respond to deterioration rather than reconsider a diagnosis from scratch.
• A second opinion is about a diagnosis or treatment plan. A second opinion allows a patient, family member or carer to ask another doctor, consultant or other relevant healthcare professional for a further view on a health condition, diagnosis or proposed treatment. It does not depend on the patient's condition getting worse, and it may take time to arrange. If you want a second opinion, speak to the doctor or consultant responsible for the patient's care, or ask the ward manager how the hospital handles second-opinion requests.

If the concern is not about urgent clinical deterioration but instead relates to communication, the hospital bed or environment, food, visiting arrangements or another service issue, the Patient Advice and Liaison Service (PALS) can provide patient advice and support. PALS is not a substitute for Martha's Rule when somebody may be becoming seriously unwell.

In short, use Martha's Rule when you are worried that an patient is becoming more unwell and needs an urgent review. Ask for a second opinion when you want another clinical view on a diagnosis or treatment plan. The distinction matters because Martha's Rule is intended to provide a rapid patient safety response to deterioration.

Where is Martha's Rule available?

All acute trusts in England are now working to implement Martha's Rule across services for adult inpatients and children receiving acute hospital care. However, hospitals remain at different stages of implementation, and in some hospitals the Rule may still operate only in certain wards or departments. Full implementation across acute inpatient services is expected during 2026/27, with the NHS Standard Contract requiring trusts to implement the Rule's three core components by 31 March 2027.

The programme is also expanding beyond its original focus on hospital inpatients. Maternity and neonatal services are being brought into the programme following the June 2026 announcement, while the A&E rollout announced in September 2026 is due to continue until March 2028.

To find out whether Martha's Rule is available where you or someone you care for is being treated:

• Check the NHS trust's website: search for “Martha's Rule” or “Call 4 Concern”. Trust websites should explain which hospitals, wards or services are covered and give the dedicated phone number where one is available.
• Ask the ward team: a ward nurse, nurse in charge, ward manager, doctor or another member of hospital staff should be able to tell you whether the Rule is operating in that area and how to use the local concern service.
• Ask PALS for general information if you still cannot find the local route: the hospital's Patient Advice and Liaison Service may be able to help you navigate local services. However, PALS is not the urgent clinical escalation route. If the patient's condition is getting worse, tell the care team immediately and use the hospital's dedicated Martha's Rule route where it is available.

There is no single national Martha's Rule phone number, so the correct contact depends on the hospital. The national rollout described in this article applies to England. If someone is receiving care elsewhere in the UK, ask the hospital or relevant local health service what escalation process applies there.

Has Martha's Rule made a difference?

The NHS says early evidence suggests the initiative is improving patient safety and leading to changes in care.

The latest published national data for September 2024 to July 2026 records 19,177 escalation calls. 72% came through the family or carer escalation process.

Of those calls, 5,660 related to acute deterioration. The data shows that 749 led to transfers to intensive care, high dependency care, enhanced care, a tertiary centre or another specialist service, while 2,683 led to other treatment changes.

These figures show that urgent reviews are changing treatment in a substantial number of cases.

How can Martha's Rule be part of a medical negligence claim?

Martha's Rule does not change the legal tests involved in a medical negligence claim. A claim still depends on evidence showing that the care provided by a doctor, nurse, surgeon or other clinician fell below a reasonable standard and that this caused or contributed to avoidable harm.

However, evidence of an escalation may provide important evidence about the sequence of events. Records can show when concerns were raised, what symptoms or changes were reported, what observations were recorded, how the ward team responded and what happened after the urgent review.

This can be relevant when investigating whether there was a delay in recognising or managing a deteriorating condition and provide evidence of how an individual’s condition had changed at a key point in time. Independent medical experts will need to consider those records alongside the wider medical evidence when assessing the standard of care and whether earlier action would probably have changed the outcome.

For more detail, read our guide to how to prove medical negligence.

Does a failure to follow Martha's Rule prove medical negligence?

No. A failure to use or follow the Rule does not automatically prove medical negligence.

The key questions remain whether the care fell below the standard reasonably expected of the relevant doctor, nurse or other clinician, and whether that caused or contributed to avoidable harm. A failure to listen to concerns, arrange an appropriate review or respond to signs of deterioration may form part of that investigation, but its significance depends on the evidence in the individual case.

Do you need to have used Martha's Rule to make a medical negligence claim?

No. A patient or family may not have known the Rule existed, the service may not have been available in that part of the hospital, or the deterioration may have happened before it was introduced. None of those points prevents us from investigating the care provided.

The central questions are what the doctors and nurses knew or should have known, what action they took, and whether different care would probably have led to a better outcome.

What Martha's Rule evidence may be relevant to a medical negligence claim?

Relevant evidence will include:

• Hospital and GP medical records
• Observation charts and early warning scores
• Nursing and medical notes recording concerns about deterioration
• Records of Martha's Rule or Call 4 Concern contacts
• Notes made by the critical care outreach team or another reviewing team
• Test results, scans and investigation records
• Records showing treatment changes or transfers to intensive care or another specialist service
• The patient's account and evidence from family members or carers who raised concerns
• Independent medical expert evidence on the standard of care and whether any failings caused or contributed to harm

You do not need to obtain all of this evidence before speaking to us. JMW gathers the relevant medical records and arrange independent medical expert evidence as part of our investigation.