Martha’s Rule expands into maternity services and A&E: what patients and families need to know

Patients and families are often the first to notice when their condition has changed. They may recognise that they are becoming confused, less responsive, increasingly breathless or simply much more unwell.

Martha’s Rule is a patient-safety initiative intended to support earlier recognition of deterioration by ensuring that concerns raised by patients, families, carers and healthcare staff are listened to and acted upon. Where those concerns remain unresolved, it provides a route to request a rapid clinical review by a different team.

Initially introduced in adult and children’s acute inpatient services, Martha’s Rule is now being extended into other areas of NHS care. On 24 June 2026, the government announced its extension across maternity and neonatal services in England. On 22 September 2026, NHS England announced a phased rollout across every hospital A&E department in England.

These developments are an encouraging step towards a healthcare culture in which patients, families and staff feel confident speaking up when they believe that someone is becoming more unwell.

What is Martha’s Rule?

Martha’s Rule is named after Martha Mills, who died in August 2021 at the age of 13. Martha had sustained a pancreatic injury following a cycling accident and subsequently developed sepsis while receiving hospital treatment.

Martha’s family repeatedly raised concerns about her deteriorating condition. Following an inquest that concluded in February 2022, the coroner found that Martha was not referred promptly to paediatric intensive care and that, had she been referred quickly and treated appropriately, she was likely to have survived her injuries.

Martha’s parents subsequently campaigned for patients and families to have a recognised route to raise the alarm where they believe someone is deteriorating and their concerns are not receiving an adequate response.

Martha’s Rule has three core components:

1. Patients are asked at least daily how they are feeling and whether their condition is improving or worsening, with that information acted upon in a structured way.
2. Staff can request a review by a different team if they are concerned that a patient is deteriorating and their concerns are not being addressed.
3. Patients, families and carers can use the same escalation route to request a rapid clinical review.

A rapid review should involve an appropriately skilled clinician who is independent of the team directly responsible for the patient’s ongoing care. The clinician should assess the concern or facilitate timely access to the right specialist, and the outcome should be explained clearly to the person who raised the concern.

Martha’s Rule is not a general second-opinion service and does not give patients a right to insist on a particular test or treatment. It is an escalation process for circumstances in which a patient may be deteriorating, and concerns do not appear to be receiving an adequate response.

Is Martha’s Rule making a difference?

The latest published data indicates that Martha’s Rule is already making a meaningful difference.

Between September 2024 and July 2026, 19,177 escalation calls were recorded. Of those, 5,660 related to acute deterioration. A total of 749 calls led to a transfer to intensive, enhanced or specialist care, while 2,683 resulted in another change to treatment. Families and carers made 72% of all calls. These figures have been published by NHS England as management information.

An interim evaluation at three early-adopter hospitals found that patients, families and staff felt Martha’s Rule amplified their voices and supported more collaborative care. It also identified areas for improvement, particularly awareness of the process, communication about action taken following a call, and access for people who may find it more difficult to speak up.

Extending Martha’s Rule to maternity and neonatal care

Earlier this year, the government committed to extending Martha’s Rule across maternity and neonatal care in England. The initiative had already been piloted in 15 maternity and neonatal settings before the wider commitment was announced.

The announcement followed publication of Donna Ockenden’s final review into maternity and neonatal services at Nottingham University Hospitals NHS Trust. Nearly 2,500 families were involved in the review, which identified recurring concerns about women and families not being listened to, missed opportunities to intervene, and weaknesses in leadership, governance and organisational learning.

The final report expressly identified the need for women, families and staff to be able to obtain an urgent additional clinical review through Martha’s Rule. It also emphasised that women should be placed at the centre of clinical communication and informed decision-making.

Under the extension, a woman, partner or family member should have a route to request a rapid review from an independent clinical team if they believe that a mother or baby is deteriorating and their concerns have not been adequately addressed.

Depending on the circumstances, concerns might include suspected maternal or neonatal infection, significant bleeding, worsening symptoms following birth or caesarean section, fetal or neonatal deterioration, or changes in a newborn baby’s breathing, feeding, colour or responsiveness. These are examples rather than formal eligibility categories.

Women and families may notice important changes before they become apparent during an isolated clinical assessment. Martha’s Rule recognises that these observations form a valuable part of the overall clinical picture.

Implementation is under way, but local pathways and coverage may vary while the rollout is completed. Families should therefore ask their hospital or NHS trust whether Martha’s Rule is available and which maternity or neonatal areas it covers. The national announcement should not be interpreted as confirmation that every community, outpatient or homebirth pathway already operates an identical process.

Martha’s Rule is an additional safeguard, not a replacement for urgent care. Anyone with an immediate maternity or neonatal concern should continue to contact maternity triage, the labour ward, NHS 111 or 999 as appropriate.

Expanding Martha’s Rule into A&E departments

Last month, NHS England announced that Martha’s Rule would be expanded across every hospital A&E department in England. Implementation is expected to be completed by the end of March 2028.

The confirmed scope includes adult and paediatric emergency care, major treatment areas, resuscitation, reception and waiting rooms, and temporary escalation spaces such as corridors. This is significant because a patient’s condition may deteriorate while they are waiting to be assessed, investigated or admitted.

The announcement followed testing in seven NHS trusts, one in each NHS region. During the pilot, which ran from September 2025 to March 2026, 69 calls were made to dedicated Martha’s Rule telephone numbers. In some cases, the review led to urgent surgery or transfer to intensive care.

The present national programme does not automatically cover same-day emergency care services, urgent treatment centres or minor injury units where they are not co-located with an emergency department. NHS England has said that implementation in those settings has not yet been tested.

How can patients and families request a review?

The first step will usually be to tell the healthcare team what has changed and why there is concern. Many issues can be addressed through further assessment, monitoring or a clear explanation.

If the patient appears to be becoming more unwell and the concern remains unresolved, patients and families can ask whether Martha’s Rule is available and how to activate it. NHS England advises families to check the relevant trust’s website or ask hospital staff about local arrangements.

When speaking to staff, a patient or their family member should explain what has changed, when it began, who has already been told and why they remain worried. A patient or relative might say: “We are concerned that the condition has become worse since the last assessment. We have raised this already, but we remain worried and would like an urgent clinical review under Martha’s Rule.”

Families do not need to diagnose the problem or prove that something is wrong. Raising a concern is an important part of patient safety, and it is appropriate to ask for a further assessment when concerns remain.

If you or a family member experienced a delay in recognising deterioration, or you feel that repeated concerns were not acted upon, you may be left with unanswered questions about the care provided. Our specialist medical negligence team understands that families often want answers and reassurance before deciding whether to take matters further. If you remain concerned that something went wrong, you can contact us for an initial, confidential conversation. We can listen to your experience, explain the options available and help you decide whether further investigation may be appropriate.