The death of Martha Mills, aged 13, following sepsis prompted national reflection on how the concerns about deterioration raised by patients and families are acted upon in acute settings. An inquest into her death highlighted failures to listen and respond to the family’s concerns, actions that could have prevented her death. Martha’s parents, supported by agencies such as Demos and the office of the Patient Safety Commissioner, called for urgent improvements to patient safety policy to address this. Martha’s Rule is now a central focus of national patient safety policy designed to ensure that the views of patients and their families about the patient’s condition are captured daily and any concerns about deterioration are taken seriously and actively responded to. This policy was rolled out in 2024 by NHS England across 143 sites acute pilot sites.
This interim report presents findings from an independent formative evaluation addressing a number of research questions about the factors that contribute to successful implementation of this policy and the potential and actual impact of the first phase of its rollout for services, healthcare staff, and patients and families. It draws on a prospective case study across three pilot sites, involving observations, interviews and documentary analysis, accompanied by a systematic review of literature and a public awareness survey conducted in collaboration with Picker.
Phase 1 of the rollout of Martha’s Rule began in June 2024, and phase 2 in April 2025. Our data were collected in three hospital sites from the early stages of their own rollout, from November 2024. Observations were carried out until September 2025, with interviews continuing through to February 2026. We conducted 63 general observations, 120 focused observations, and 115 interviews, whilst ensuring a diverse sample. Additionally, we have completed a systematic review and a public survey of 2047 respondents. Interim analysis of this multi-source data revealed that a third of the public and patients and family are aware of Martha’s Rule. Each site had developed its own approach to implementation, adapting their strategy and/or delivery model as rollout progressed. Moreover, all components of Martha’s Rule are evident at sites, with the Patient Wellness Questionnaire (PWQ) selected as the Trusts’ preferred tool for obtaining daily information on the patient’s condition – this was only implemented on a small number of wards in each site prior to further rollout across the Trust. Patients, family and staff reported that MR amplifies their voices and promotes collaborative care in acute settings. Alongside this progress, a number of challenges were identified. These included: an observed shift in how the PWQ 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; and barriers to access for some groups that may be most in need of Martha’s Rule.
The interim report is now available highlighting key findings and implications for policy makers, further rollout and onward research. These findings have already been used to inform national guidance, including the development of the Martha’s Rule core standards.
The final report of this evaluation is expected to be published in the Summer.
For any questions or comments, please email marthasrule.study@bthft.nhs.uk
The Problem