Martha’s Rule and building a joined-up approach to patient safety

Estimated reading time:  4 minutes

The recent update from NHS England about the positive impact of Martha’s Rule is a welcome and important step forward for patient safety. It recognises that when someone is deteriorating in hospital, there must be a clear and reliable way to raise concerns and trigger urgent review. Early evidence suggests that it is already saving lives, and that is something to be welcomed. 

But Martha’s Rule also teaches us something uncomfortable. It shines a light on who is most able to benefit from escalation mechanisms – and, just as importantly, who is not.

Martha’s Rule is saving lives – but not reaching every patient who needs it

At its heart, Martha’s Rule depends on someone being able to speak up. That might be a patient, a relative, or a member of staff who feels confident enough to challenge decisions or ask for a second opinion. For some people, that is possible. For many others, it is not. 

At AvMA, we hear daily from families after serious harm or death who say, “If only we had known what to ask,” or “There was no one there to speak for them.” These are not marginal cases. They are people who were very ill, frightened, isolated, or simply unsure that they were allowed to question what was happening to them. 

A safety system that relies primarily on patients or families to activate safeguards will always leave some people behind. That is not a criticism of Martha’s Rule – it is a recognition of its limits. 

If we are serious about patient safety, we must design systems that protect not only those who can speak up, but also those who cannot.

Every patient deserves an independent advocate – especially those who cannot speak up for themselves 

This is where the need for effective patient advocacy becomes critical, particularly in high-risk clinical settings. In many areas such as maternity (where there has until recently been a successful trial of employing senior independent advocates), as well as acute medicine, mental health, and complex surgery, we should not expect situations where patients are assumed to advocate for themselves. 

Effective patient advocacy does not require confrontation, nor does it undermine clinical expertise. At its best, it provides an additional layer of protection for patients whose voices are not being heard. It helps bridge the gap between clinical decision-making and the lived reality of patients and families. 

Martha’s Rule should therefore be seen as part of a wider safety net – one that includes proactive, independent forms of patient advocacy, rather than as a standalone solution. 

NHS England and the Department of Health must prioritise funding independent patient advocacy roles in high-risk clinical settings. When piloted in maternity and neonatal services the evaluation of their benefits and impact was clear.¹

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1 Nuffield Trust evaluation of the MNISA pilot in England 

When NHS patients are harmed, how organisations respond determines whether recovery is possible 

But even with the best escalation mechanisms and advocacy in place, we must be honest about another reality: harm will still occur. When it does, what happens next can either support healing or compound the damage.

For too many people who come to AvMA after harm, the experience does not improve once the immediate clinical crisis has passed. Instead, they encounter defensiveness, poor communication, fragmented processes, and a lack of clear responsibility.

This is why AvMA, working with the Harmed Patients Alliance, developed the Harmed Patient Pathway. The Pathway is not a new investigation process, nor another layer of bureaucracy. It is a clear, values-based framework that sets out how healthcare organisations should respond when patients are harmed.

High-risk clinical environments should assume – not hope – that harm will sometimes occur. Just as we plan for deterioration, we must plan for what follows harm. A defined harmed patient pathway ensures that patients and families are not left abandoned at precisely the moment they are least able to cope.

The Harmed Patient Pathway offers a practical starting point, not an overnight transformation. Organisations can begin at a manageable scale, building confidence and learning as they go. If you would like to explore what implementation could look like for your organisation, register your interest here and we will be in touch.

Martha’s Rule, patient advocacy, and the Harmed Patient Pathway: a joined-up approach to NHS patient safety

Seen together, these issues are not separate. Martha’s Rule addresses what happens before harm becomes catastrophic. Patient advocacy protects those who cannot speak up. The Harmed Patient Pathway governs what happens after harm has occurred. All three are part of the same ethical commitment to patient safety.
Martha’s Rule matters because it challenges a culture in which patients and families were too often ignored. But if we truly want a safer healthcare system, we must go further.

The tools exist. The frameworks are ready. What remains is for the Department of Health, NHS England, and every Hospital Trust to act on what we already know: that every patient deserves a system that protects them, encourages them to speak, and supports them when things go wrong.