Researchers from the NIHR Patient Safety Research Collaboration (PSRC): Greater Manchester are contributing to a major national study investigating how Martha’s Rule is being implemented across NHS hospitals in England, drawing on qualitative and health economics expertise to generate evidence on its impact on patient safety and care.

The Martha’s Rule evaluation study, funded by the National Institute for Health and Care Research (NIHR), will identify the best ways to ensure patients, families and healthcare staff are heard when they have concerns about a patient’s deterioration.

What is Martha’s Rule?

Martha’s Rule is an initiative introduced following the teenager’s death at King’s College Hospital in 2021. It is named in memory of Martha Mills, who died after a failure to escalate her care led to her death from sepsis. The rule was introduced following the campaign led by Martha’s mother, Merope Mills.

It is designed to give patients and families the opportunity to report daily how they are feeling and if their condition has changed, and to seek an urgent review from an independent team if they have concerns about a patient’s worsening condition. It is currently being put in place by all NHS Trusts across England following a pilot phase across dozens of hospitals.

Now, a major review is being launched to investigate how well the rule is being implemented and where improvements could be made.

It brings together leading patient safety researchers, clinicians, patients and public contributors to examine how Martha’s Rule is working in practice.

Bringing together expertise from across England

The national evaluation is being led by the NIHR Patient Safety Research Collaboration (PSRC): Central London and delivered by SafetyNet, through a collaboration between all six NIHR PSRCs which carry out research to improve patient safety across England.

The three-year research programme brings together expertise from across the network under the leadership of Professor Ramani Moonesinghe and John Welch, both consultants at University College London Hospitals (UCLH) and leaders within the NIHR PSRC: Central London.

The NIHR PSRC: Greater Manchester, alongside researchers from the universities of Leicester and Manchester, will play a key role on the qualitative and health economic workstreams of the Martha’s Rule evaluation, including how patients, families and staff are supported and empowered to speak up for safety and raise concerns about care.

The qualitative workstream of the evaluation will be co-led by Professor Nicola Mackintosh with support from Dr Liz Sutton, from the University of Leicester and the NIHR PSRC: Greater Manchester’s Enhancing Cultures of Safety research theme. Together they have a portfolio of related work conducted over the past 10 years in patient and family involvement in safety, and in the design of safety tools to enable the rescue of deteriorating patients on hospital wards.

Professor Mackintosh said:

“We know that patients and family members can play a central role in contributing to timely management of deterioration. Martha’s Rule offers a way for their voices to be routinely heard. The qualitative workstream will enable us to understand how Martha’s Rule is being implemented across different settings, its influence on local cultures of safety, and factors that shape equitable provision of Martha’s Rule for all.”

The Martha’s Rule evaluation also draws on health economics expertise from the NIHR PSRC: Greater Manchester team, led by Professor Rachel Elliott and Dr Thomas Allen from The University of Manchester. The evaluation with help determine the cost implications and economic benefits for hospitals implementing Martha’s rule.

Professor Darren Ashcroft, Director of the NIHR Greater Manchester PSRC, said:

“Martha’s Rule has the potential to strengthen patient safety by ensuring that patients and families have a clear route to raise concerns when a patient’s condition is deteriorating. This evaluation is an important opportunity to understand how the policy is being implemented in practice, what works well, and where further improvements may be needed. By drawing on our expertise in qualitative research and health economics, we are delighted to contribute to this important national study and help build the evidence needed to support safer care for patients and families.”

The study will provide the first comprehensive national evaluation of the initiative, generating evidence to inform the future development of Martha’s Rule across the NHS. It follows on from an interim evaluation report – funded through the NIHR Policy Research Unit (PRU): Quality, Safety and Outcomes of Health and Social Care PRU – which looked in-depth at 3 early-adopting hospital sites between November 2024 and February 2026.

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