Executive Summary
This policy sets out the Trust’s approach to implementing Martha's Rule, ensuring that patients, families, carers, and staff have access to a clear and effective process for escalating concerns about a patient's clinical condition. The policy supports a culture of openness, patient safety, and shared decision-making by empowering individuals to request an urgent clinical review when they believe a patient's condition is deteriorating and their concerns have not been adequately addressed.
The purpose of the policy is to strengthen the early recognition and response to deterioration, reduce the risk of avoidable harm, and improve communication between patients, families, carers, and healthcare professionals. It complements existing clinical escalation pathways and does not replace established emergency response systems or professional clinical judgement.
The policy outlines the responsibilities of all staff in responding promptly and respectfully to concerns, the process for initiating a Martha's Rule review, governance arrangements for monitoring compliance, and mechanisms for learning from escalations to support continuous improvement. It also ensures that information about Martha's Rule is accessible to patients, visitors, and staff, promoting awareness and confidence in the escalation process.
By embedding Martha's Rule into everyday clinical practice, the organization aims to foster a compassionate and transparent safety culture, improve patient experience, and ensure that concerns about deterioration are acted upon quickly and consistently. The policy aligns with national patient safety priorities and reinforces the organization's commitment to delivering safe, responsive, and person-centred care.
Policy Details
| Download: | PDF version |
| Compiled by: | Sue Wilson, Martha’s Rule Clinical Project Lead Dr Nik Shah, Deteriorating Patient Clinical Lead Jenni Davidson, Head of Patient Safety and Mortality |
| Ratified by: | Practice Standards Committee |
| Date Ratified: | July 2026 |
| Date Issued: | September 2026 |
| Review Date: | August 2029 |
| Target Audience: | All clinical staff |
| Contact name: | Sue Wilson, Martha’s Rule Project Lead |
See also:
- Deteriorating Adult In-Patient Policy
- Inter-Facility Transfer Policy for Ashford Hospital to St Peter’s Hospital / Tertiary Care Centres
- Resuscitation Policy
- Neonatal Deterioration: Escalation and Monitoring Guidelines
- Suspected sepsis in under 16s: recognition, diagnosis and early management; NG254
- Deterioration and Enhanced Maternal Care Guideline
