Martha’s Rule is moving beyond inpatient wards and into more hospital settings, including emergency departments. For patients and families, that matters because the rule is designed to provide a clear way to ask for an urgent review when they are worried that a patient is getting worse and their concerns are not being acted on.
NHS England says Martha’s Rule is being introduced across acute services in England, with phase 3 extending the programme into emergency departments, maternity and neonatal settings during 2026. The NHS England Martha’s Rule guidance explains that patients, families and staff should have access to an escalation route for concerns about deterioration.
The rule does not replace normal clinical care, and it is not a complaints procedure. It is intended for situations where someone believes a patient may be deteriorating and needs an urgent clinical review.
What Martha’s Rule is designed to do
Martha’s Rule was introduced after the death of 13-year-old Martha Mills, whose family had raised concerns about her deterioration. The programme aims to make escalation easier and more consistent when patients, families or staff believe a person’s condition is worsening.
The core idea is simple: if you are seriously worried that a patient is getting worse and you do not believe those concerns are being addressed, there should be a route to request an urgent review by a different clinical team.
NHS England’s programme also includes staff escalation, because healthcare workers themselves may sometimes be concerned that a patient needs a second review.
Why the A&E expansion matters
Emergency departments are busy, fast-moving environments. Patients may be waiting for tests, results, a treatment decision, admission or discharge. Symptoms can also change while someone is waiting.
Families often know what is normal for the person they are supporting. They may notice that someone has become unusually sleepy, confused, breathless, weak, agitated or difficult to wake. A relative may also know that a symptom is significantly different from the person’s usual presentation.
Martha’s Rule is intended to provide a formal escalation route when those concerns are serious and unresolved. It should not mean that every delay or disagreement triggers an emergency review, but it creates another safety mechanism when deterioration may be missed.
When should a patient or family consider using it?
The most important question is whether you are worried about clinical deterioration, not whether you are dissatisfied with a general aspect of care.
Examples might include a patient whose breathing is getting worse, a person becoming increasingly confused or difficult to wake, severe pain that is escalating, rapidly changing observations, or a significant change from the patient’s normal condition that has not been adequately reassessed.
Before using the formal escalation route, it is usually appropriate to tell the nurse, doctor or other clinical staff what has changed and why you are worried. Be specific. Saying “something is wrong” is less useful than explaining that the patient is now much more drowsy, has become newly confused, is struggling to breathe, or is no longer responding as they did earlier.
If you believe the concern is still not being addressed, ask whether Martha’s Rule is available in that hospital or department and how to activate it.
What to say when raising a concern
Families do not need medical vocabulary. A clear timeline is often more useful.
- Explain what the patient was like earlier.
- Describe what has changed.
- Say when the change started.
- Mention important medical conditions or recent procedures.
- Explain why the change worries you.
- Ask what assessment has been done and what is planned next.
If you have a list of current medicines, allergies, recent discharge information or relevant letters, keep them available. Our Healthcare Navigation guide explains how to organise this information so it can be shared quickly when a patient moves between services.
Martha’s Rule is not the same as a second opinion for everything
The phrase “second opinion” can be misleading. Martha’s Rule is specifically about concerns that a patient may be deteriorating and needs urgent clinical review. It is not primarily intended to resolve routine disagreements about long-term treatment choices, waiting-list decisions, elective procedures or non-urgent complaints.
Hospitals already have complaints and patient-advice routes for broader concerns. Martha’s Rule sits alongside those systems as a patient-safety mechanism.
What the programme has shown so far
NHS England has published data from the programme showing that patients, families and staff have used Martha’s Rule escalation routes to trigger additional reviews. In May 2026, NHS England reported that more than 1,000 staff calls had been made in the first 18 months, with many identifying acute deterioration.
Those figures do not mean the rule is needed in every case. They do show why an independent escalation route can matter when someone close to the patient or a member of staff remains worried.
What carers should know before a hospital visit
Family carers can prepare without expecting a crisis. Keep a concise list of diagnoses, medicines, allergies, communication needs and important recent changes. If the person has difficulty communicating pain or symptoms, make that clear to staff early.
For people living with dementia, learning disability, neurological conditions or communication difficulties, relatives may be particularly important in explaining what is normal for that person.
Our Family Carers & Home Recovery guide includes practical advice on tracking symptoms and changes before and after hospital care.
What if the hospital has not fully implemented Martha’s Rule?
NHS England says acute trusts are at different stages of implementation, so availability may vary by hospital and department while rollout continues. If you cannot find clear information, ask a member of staff whether the hospital has a Martha’s Rule or Call for Concern service and how patients or families can access it.
If someone appears to be in immediate danger, do not wait to locate a special escalation number. Tell staff directly that the patient is deteriorating and needs urgent assessment.
How to avoid turning escalation into confrontation
Patient safety is best served when concerns are specific and focused on the patient’s condition. Try to separate urgent clinical concerns from frustration about waiting times, communication or service organisation.
A useful approach is: “I am worried because this is a significant change from their normal condition. Could someone reassess them now and explain what is being done?”
If you still believe deterioration is being missed, ask for the formal escalation route.
The bottom line
Martha’s Rule gives patients, families and staff another route to request an urgent clinical review when they are seriously worried about deterioration. Its expansion into emergency, maternity and neonatal settings is intended to make that safeguard available in more places where rapid changes in a patient’s condition can occur.
The most useful thing families can do is recognise meaningful change, communicate it clearly, know how to ask for reassessment and use the formal escalation route when serious concerns remain unresolved.
What families should know about escalation in practice
In a busy hospital, it can be difficult to know whether a change in condition has already been noticed by staff. That is why specific observations are useful. If a patient was alert earlier and is now difficult to wake, say exactly that. If breathing has become faster or more laboured, explain when the change began. If pain has changed sharply, describe the difference rather than simply saying it is “worse.”
Families should also ask what has already been checked. It is reasonable to ask whether observations have been repeated, whether a doctor has reviewed the patient, whether blood tests or imaging are pending and what the team is watching for next. Clear questions can reduce misunderstanding and help the family understand whether a concern has already been acted on.
What Martha’s Rule does not guarantee
Martha’s Rule gives a route to request review; it does not guarantee that the reviewing team will agree with the family’s interpretation or change the treatment plan. The value of the rule is that a serious concern about deterioration can be heard and assessed independently rather than dismissed because the first team has already formed a view.
It also does not mean that every long wait in A&E is unsafe. Emergency departments prioritise according to clinical need, and some patients who wait several hours may remain stable. The trigger for escalation is concern about deterioration or an important change that may need reassessment.
Patients who may need extra support to use the rule
Some patients may find it difficult to activate an escalation route themselves. This can include people with dementia, learning disability, communication difficulties, severe illness, language barriers or reduced consciousness. Families, carers and advocates can therefore play an important role in noticing deterioration and making sure concerns are clearly communicated.
Hospitals should also provide accessible information about how to use the service. Where English is not the patient’s first language, an interpreter may be appropriate. Where the patient uses a communication aid or has a known reasonable adjustment, staff should take that into account.
After an urgent review
If an escalation leads to a review, ask what the reviewing clinician found and what happens next. The plan may involve immediate treatment, further tests, closer monitoring, transfer to another area or reassurance that the current plan remains appropriate.
Families should make a short note of the outcome, particularly if the patient remains in hospital for several days. This creates a useful timeline and can help when different teams take over care.
Why awareness matters
A safety system only works if people know it exists. As Martha’s Rule expands, hospitals will need to make the escalation route visible and understandable to patients and families. Posters and leaflets help, but staff should also explain the route when a patient or relative expresses persistent concern about deterioration.
The practical value for families is not in memorising policy language. It is in knowing that serious concerns about worsening condition can be escalated and that asking for another review is an accepted part of the safety process.
This article provides general information about NHS patient-safety processes. Availability and local procedures can vary by trust and department, so check the hospital’s current guidance.
Families can also ask the hospital to explain where the Martha’s Rule contact details are displayed and who will respond if the route is activated, so they know the process before a crisis develops.
