HSE engages with NHS on ‘Martha’s Rule’

The HSE is considering how the principles underpinning Martha’s Rule could be supported within the Irish system. Catherine Reilly reports

The HSE has engaged with the NHS to “learn from” its experience of implementing ‘Martha’s Rule’, an Executive spokesperson has informed the Medical Independent (MI).

Martha’s Rule aims to support the early detection of clinical deterioration in hospitals. The policy is named after Martha Mills (13), who died in 2021 after developing sepsis in King’s College Hospital, London.

Martha was admitted to the paediatric liver ward with a pancreatic injury after a fall from her bike. An inquest heard that there were several missed opportunities to escalate Martha’s care. Her parents’ repeated concerns about her deteriorating condition were not acted upon.

The coroner found that, whilst at King’s College Hospital, Martha should have been referred to paediatric intensivists at an earlier stage, and this action would likely have led to her survival.

Martha’s parents, Merope Mills and Paul Laity, campaigned for urgent improvements to patient safety policy nationally. In 2023, the Secretary of State for Health and Social Care and NHS England committed to implementing Martha’s Rule across the NHS. Implementation commenced in 2024.

Components of Martha’s Rule

The components of Martha’s Rule are based on recommendations by the Patient Safety Commissioner for England, Prof Henrietta Hughes, following a stakeholder engagement process.

Under Martha’s Rule, patients should be asked, at least daily, how they are feeling and if they are getting better or worse and this information should be acted upon in a structured way.

Patients, families, carers, and staff must be able to request, at any time, an urgent review by an alternative clinical team if they feel their concerns about deterioration are not being addressed. This requires hospitals to establish a dedicated phone number that patients, families, and staff can call. The rapid review is usually conducted by a critical care outreach team/practitioner.

Martha’s Rule does not replace hospitals’ existing monitoring and escalation processes. The policy should be integrated into broader patient safety, deteriorating patient management, and quality improvement systems. Martha’s Rule “can work alongside existing physiological scoring systems to increase the sensitivity of identifying and responding to acute deterioration”, according to the NHS.

The policy also reflects an increasing recognition in healthcare that the concerns of the patient, family or caregiver can play an important role in detecting deterioration.

In May 2024, a pilot began in 143 sites with 24/7 access to a dedicated critical care outreach team. Prof Stephen Powis, the then National Medical Director of NHS England, described the commencement of Martha’s Rule as “one of the most important changes to patient care in recent years”.

The reported funding allocation for the first phase of roll-out (May 2024-March 2025) was up to £10 million. Its implementation in all 210 adult and paediatric acute inpatient sites in NHS England is expected to be completed during 2026/27. The policy is also being rolled out to maternity and neonatal services (and being tested in some other services). According to NHS England, a national programme team provides implementation support to sites.

Early warning systems

HSE National Quality and Patient Safety (NQPS) is reviewing the clinical guidelines for the four national early warning systems. It has engaged with the NHS on Martha’s Rule within this broader context.

The feedback from NHS colleagues has indicated that Martha’s Rule functions as an “important adjunct” to early warning systems, stated the HSE. Martha’s Rule can help to identify clinical deterioration at an earlier stage, including situations where concern is evident to patients, families, or staff before physiological deterioration is reflected in early warning scores.

The four national early warning systems are: The Irish national early warning system (INEWS); the Irish maternity early warning system (IMEWS); the paediatric early warning system (PEWS); and the emergency medicine early warning system (EMEWS). Work on a paediatric early warning system in emergency medicine will also be incorporated within this review.

As of March 2026, HSE data showed 45.8 per cent of public acute hospitals were implementing INEWS in all clinical areas. Some 64 per cent were implementing PEWS, while 78.9 per cent of maternity hospitals/units had fully implemented IMEWS. Some 44.2 per cent of all public hospitals were implementing IMEWS. The HSE has targeted 100 per cent implementation.

“Variations in compliance can arise from a range of factors, including documentation practices, workforce and operational pressures, training requirements, local service arrangements, and differing levels of digital enablement across healthcare settings,” according to the Executive.

The HSE spokesperson said the review of the guidelines is part of “routine” work. “National clinical guidelines require ongoing implementation and continuous adaptation to updates in evidence, clinical practice, technology and organisational governance.”

The guidelines have also “undergone updates since their initial introduction and have been informed by evolving national and international evidence”.

Based on preliminary consultations with staff, HSE NQPS has proposed to review the four clinical guidelines concurrently.

“The model is expected to improve consistency, reduce duplication, and support more timely updates to all four guidelines and the development of the paediatric early warning system in emergency medicine.”

The process is designed to “build national consensus on core principles and minimum specifications”; enable context-specific implementation; and consider the implications of future digitalisation across different clinical settings and professional groups.

HSE NQPS is partnering with the University of Limerick’s Centre for Implementation Research to incorporate an “implementation science” perspective throughout the review and subsequent implementation phases.

“The proposed work of this coordinated review, particularly in relation to patient input and activation, escalation processes, governance, education, and implementation, represents an important scoping and foundational step in considering how the principles underpinning Martha’s Rule could be supported within the Irish system and incorporated into future approaches to the recognition and escalation of deterioration,” added the HSE spokesperson.

“A National Clinical Lead for the Deteriorating Patient Improvement Programme has been assigned to this work.”

It is expected that the review will conclude in December 2027.

NHS data

According to the NHS, early evidence suggests Martha’s Rule is saving lives and helping patients benefit from changes to their care. The number of calls has increased in line with implementation.

From September 2024 to June 2026, 17,490 Martha’s Rule calls were received in NHS England hospitals (this is within the context of about 1.5 million admissions per month nationally). The highest proportion of calls came via families/carers (72 per cent), shows the NHS data.

Some 2,353 calls were made by staff, with 1,390 of these calls (59 per cent) categorised as ‘acute deterioration calls’ (ie, Martha’s Rule escalation calls that have been reviewed and identified as relating to acute deterioration).

In total, 5,299 calls (30 per cent) helped to identify acute deterioration. Some 685 calls (13 per cent of acute deterioration calls) required transfers of care to an intensive care unit/high-dependency unit, enhanced levels of care, tertiary centre, or referral/transfer to specialists or a specialist ward. Some 2,489 calls (47 per cent of acute deterioration calls) required other changes in treatment.

Between June 2025 and June 2026, an early warning score was recorded prior to 3,144 of 3,349 Martha’s Rule calls that related to acute deterioration (94 per cent). For most of these calls, the early warning score recorded prior to the call would not otherwise have triggered escalation (82 per cent), and of these, most led to a transfer of care or other change in treatment (13 per cent; 56 per cent).

According to the NHS, calls that are not categorised as acute deterioration still support staff to “provide better care for patients and address concerns”.

Some 12,191 calls (70 per cent) did not relate to acute deterioration, of which 4,642 were categorised as a “clinical concern” (including medication issues, management of long-term conditions, and delayed investigations). A further 4,470 were categorised as a “communication issue” (including discharge planning).

Demographic data is only collected for those calls identified as acute deterioration. There was a statistically significant lower percentage of these calls relating to patients of black or black British ethnic groups and other ethnic groups, than the percentage of finished consultant episodes in the same ethnic groups. There was a statistically significant higher percentage of acute deterioration calls concerning patients from white ethnic groups than the percentage of finished consultant episodes in that same ethnic group.

Acute deterioration calls were more likely to involve patients from higher levels of deprivation than the general inpatient population.

Principles

Upon its launch, the General Medical Council and Nursing and Midwifery Council stated Martha’s Rule was strongly aligned with their professional codes. The Patients Association described the policy as “a major step for patient-centred care”.

Several UK medical organisations also welcomed the establishment of Martha’s Rule, while emphasising the need for investment in critical care outreach services. A number of organisations also underlined the importance of equitable access to Martha’s Rule nationally.

Some UK clinicians have called for greater scrutiny of the policy’s effectiveness. A paper recently published in Advances in Perioperative Care, ‘Martha’s Rule: A policy critique’ (Sara et al), noted that the policy had prompted debate among some clinicians. “For most clinicians, this unease does not reflect resistance to patient involvement, but concern regarding the evidentiary basis, implementation strategy and operational consequences of a national roll-out with limited prospective evaluation or consultation.”

According to the authors, the principles of Martha’s Rule – listening to patients, flattening hierarchies, and improving responses to deterioration – are “widely supported”, but its development and implementation warrant examination.

They stated: “Without parallel investment in ward capacity, workforce capability and governance, escalation focused interventions risk shifting responsibility towards critical care, rather than addressing upstream constraints.”

From a policy perspective, they said creating new escalation routes may be insufficient to address failures arising from how existing pathways are used, respected or bypassed.

The authors outlined that critical care outreach teams are configured to assess and manage acute clinical instability and physiological deterioration. “However, national data suggest that a substantial proportion of [Martha’s Rule] calls relate not to physiological deterioration, but instead to poor communication, delayed investigations, or discharge planning. Whilst important, these issues may be more appropriately addressed through ward-based senior review and care coordination.

“The routine diversion of such concerns to outreach risks blurring roles and misaligning expertise, potentially reducing the capacity for assessment and management of acute clinical instability. Preserving these functions is essential if patient-activated escalation pathways are to function effectively and remain sustainable within perioperative systems.”

The paper suggested a need for greater detail on the changes to patient management following calls relating to acute deterioration where early warning scores would not otherwise have triggered escalation.

Evaluation of Martha’s Rule must also be situated within the wider NHS context, they outlined.

“Many of the challenges it seeks to address – delayed recognition of deterioration, communication failures and reluctance to escalate – reflect not only culture, but sustained workforce and resource constraints within an increasingly overextended system.

“Much responsibility for clinical risk has gradually migrated towards critical care services, which function increasingly as the final common pathway for uncertainty and system strain. Whilst outreach models may improve outcomes, expansion of their remits risks normalising underinvestment upstream.”

The paper also raised issues regarding the patient wellness questions, including “limited standardisation” in how the questions are framed, recorded or interpreted in relation to clinical risk.

In-depth evaluation

The NHS has said that independent evaluation will inform the ongoing implementation of Martha’s Rule.

In June, the National Institute for Health and Care Research (NIHR) announced a three-year study to evaluate implementation.

This NIHR-funded study will be the first comprehensive national evaluation of the initiative. It is expected to generate evidence to inform the ongoing development of Martha’s Rule across the NHS.

Researchers will analyse data from all acute NHS hospitals implementing Martha’s Rule “to understand how different approaches to implementation affect patient safety outcomes”. In addition, the study will entail “detailed work” in 16 NHS Trusts in a range of hospital settings, patient populations, and regions. The team will explore how Martha’s Rule is being delivered and experienced by patients, families, and healthcare professionals.

According to the NIHR, a “central focus” will be understanding whether the policy helps address inequalities in patient safety.

“The programme will also assess the wider impact of Martha’s Rule on NHS services, examining how it affects clinical workloads, specialist review teams and healthcare resources.”

Patients and family members with lived experience of serious deterioration and patient harm will have “a central role throughout the study”.

Existing research

A separate NIHR-funded report has presented initial findings from an independent formative evaluation of Martha’s Rule implementation.

The evaluation has examined several research questions about the factors that contribute to the policy’s successful implementation, and the potential and actual impact of the first phase of roll-out for services, healthcare staff, and patients and families. It also draws from a prospective case study across three pilot sites, as well as a systematic review of literature and a public awareness survey conducted in September 2025.

According to the interim report, one in three people (public, patient, and family) were aware of Martha’s Rule.

“Each site had developed its own approach to implementation, adapting their strategy and/or delivery model as roll-out progressed,” it outlined.

It found patients, families, and staff valued Martha’s Rule for its ability to amplify their voices, facilitate open communication, promote collaborative care, and improve the escalation pathway between ward and critical care outreach teams.

As with any “complex intervention”, the researchers noted that challenges in the early phases of implementation were to be expected.

The challenges included: “An observed shift in how the PWQ [patient wellness questionnaire] was operationalised, with more informal approaches replacing its intended use; limited information and framing of the PWQ for patients and family; inconsistent communication about actions following rapid response; additional demands and emotional burden on responding teams; and barriers to access for some groups that may be most in need of Martha’s Rule.”

The interim report set out recommendations to inform and improve implementation, which have been fed back to policymakers.