Martha’s Rule Extended to A&E: What Does It Mean for Patients?

Patients and their families will have a new way to raise concerns if they believe someone’s condition is deteriorating while being treated in A&E.

A major change to patient safety in NHS emergency departments is being introduced in England.

From September 2026, Martha’s Rule is being extended to hospital A&E departments across England, giving patients, relatives and NHS staff an additional way to raise concerns and request an urgent clinical review where they believe a patient’s condition is getting worse and those concerns are not being adequately addressed.

The rollout follows an eight-month pilot involving seven NHS trusts. During the pilot, 69 calls were made under the A&E version of the scheme, with some patients subsequently requiring urgent surgery or transfer to intensive care. The full rollout is expected to be completed by March 2028.

For patients attending A&E, particularly at a time when emergency departments are under enormous pressure, the change could be significant.

What is Martha’s Rule?

Martha’s Rule was introduced following the death of 13-year-old Martha Mills, who died from sepsis in 2021 while receiving treatment at King’s College Hospital.

Martha’s parents repeatedly raised concerns about their daughter’s deteriorating condition. A subsequent inquest found that she would probably have survived if she had been transferred to intensive care earlier.

Her parents, Merope Mills and Paul Laity, subsequently campaigned for changes to the way patients and families can raise concerns about deterioration in hospital.

Martha’s Rule was introduced in NHS hospitals in England in 2024.

The principle is straightforward:

If a patient or their family is seriously concerned that the patient’s condition is getting worse, their concerns should be heard and there should be a mechanism for obtaining an urgent review.

The initiative has already been used extensively on hospital wards. NHS England reported that the number of calls under Martha’s Rule reached a record 1,678 in July 2026.

Now the initiative is being extended to A&E.

Why is Martha’s Rule particularly important in A&E?

A&E departments are different from many other areas of a hospital.

Patients arrive with a huge variety of symptoms and injuries. Some conditions are immediately obvious. Others are much more difficult to diagnose. A patient may initially appear relatively well but deteriorate while waiting. Another patient may have symptoms which could be caused by several different conditions. Doctors and nurses may have to make important decisions with limited information and in an extremely busy environment.

There can also be long waits, pressure on staff, difficulties obtaining investigations and challenges in transferring patients to other parts of the hospital.

All of these factors can increase the importance of recognising when a patient’s condition is changing.

Martha’s Rule is intended to provide an additional safety net.

How will Martha’s Rule work in A&E?

The precise arrangements will vary between hospitals, but the central principle is that patients, their families and staff will have access to a mechanism for requesting an urgent clinical review.

If someone believes that a patient is becoming significantly worse and their concerns are not being adequately addressed, they will be able to use a dedicated telephone number or other locally advertised mechanism to request a review.

This is particularly important for patients who may be waiting in an A&E department.

A family member may notice that someone has become:

• increasingly confused;
• unusually drowsy;
• short of breath;
• pale or clammy;
• increasingly distressed or in severe pain;
• less responsive;
• unable to communicate normally; or
• significantly different from when they first arrived.

Family members may also notice changes which are difficult to communicate during a brief clinical assessment.

The purpose of Martha’s Rule is not to allow patients or relatives to make their own medical diagnosis.

It is about ensuring that genuine concerns about deterioration are not ignored.

Martha’s Rule is not about challenging every medical decision

It is important to understand what Martha’s Rule does and does not mean.
It does not mean that every patient is entitled to demand a different diagnosis.
It does not mean that every disagreement between a doctor and a patient will result in a second opinion.

And it does not mean that a doctor has necessarily acted negligently simply because a patient or relative remains concerned.
Instead, it provides an escalation mechanism when there is a serious concern that a patient’s condition is deteriorating and that concern has not been adequately addressed.

That distinction is important.

The aim is early recognition of deterioration and patient safety, rather than replacing the clinical judgment of the treating team.

Why listening to patients and families matters

Patients and relatives can sometimes identify changes in a person’s condition which may not be immediately apparent from a set of observations or a single clinical examination.

A person who knows the patient well may recognise that:

“This isn’t normal for them.”

That observation can be extremely important.

The story behind Martha’s Rule is a powerful reminder of what can happen when concerns about deterioration are not sufficiently acted upon.

The introduction of the Rule represents an attempt to create a stronger culture in which patients and families feel able to speak up and healthcare professionals are encouraged to listen and respond.

Could Martha’s Rule help prevent missed diagnoses?

Potentially, yes.

One of the most significant risks in A&E is that a serious condition may initially be missed or incorrectly diagnosed.

A patient may attend with symptoms of:

• sepsis;
• a heart attack;
• a stroke;
• internal bleeding;
• bowel obstruction;
• a serious infection;
• a significant fracture;
• head injury; or
• another potentially life-threatening condition.

The initial presentation may not always be obvious.

If the patient subsequently deteriorates, however, that change may provide an important additional indication that something more serious is happening.

Martha’s Rule gives patients, relatives and staff an additional route to escalate those concerns.

It therefore sits alongside rather than replaces proper clinical assessment, investigation, monitoring and senior medical review.

What does this mean for medical negligence?

Martha’s Rule does not change the legal test for medical negligence.

The fact that a patient or relative raised concerns does not automatically mean that negligence has occurred.

Equally, the existence of Martha’s Rule does not remove the responsibility of healthcare professionals to provide appropriate care.

A medical negligence claim may arise where, for example, there is evidence that healthcare professionals failed to:

• properly assess a patient’s symptoms;
• recognise significant warning signs;
• carry out appropriate investigations;
• respond appropriately to abnormal test results;
• monitor a deteriorating patient;
• seek appropriate senior or specialist advice;
• respond appropriately when a patient’s condition changed; or
• provide appropriate treatment within a reasonable timeframe.

The crucial issue remains whether the standard of care fell below what could reasonably be expected and whether that failure caused or materially contributed to the patient’s injury.

What if a patient raises concerns but nothing changes?

This is likely to be one of the most important questions surrounding Martha’s Rule.

The purpose of the system is to create a mechanism for concerns to be escalated. If a patient or relative believes that someone is deteriorating, they should not be afraid to communicate that concern to medical staff. If the concern is not adequately addressed, Martha’s Rule is intended to provide an additional route to request a rapid review. This is particularly relevant in A&E, where a patient may still be waiting to be assessed, waiting for test results or waiting to be transferred elsewhere in the hospital.

The ability to say “I am seriously concerned that this patient is getting worse and I don’t think this has been properly addressed” may provide an important additional safety mechanism.

Martha’s Rule and the pressures facing A&E

The introduction of Martha’s Rule comes at a time when A&E departments are experiencing significant pressures.

Patients can face lengthy waits, emergency departments can become overcrowded and medical staff may be dealing with very large numbers of patients.

These pressures make effective communication even more important.

A busy A&E does not mean that every delay amounts to negligence. Nor does the involvement of a junior doctor automatically mean that care has been inadequate. But where pressure, staffing difficulties, inadequate supervision, communication failures or delays contribute to a patient receiving substandard treatment and suffering avoidable harm, those circumstances may need to be investigated.

Martha’s Rule is therefore an important development in the wider discussion about patient safety in emergency medicine.

Patients should feel able to speak up

Ayoub Khan, Managing Director of Aston Knight Solicitors, said:

“Martha’s Rule is an important development because patients and their families are often the people best placed to notice when something is not right. A&E departments are incredibly busy environments, and we recognise the enormous pressure that doctors and nurses are working under. But when a patient’s condition is deteriorating, concerns need to be listened to and acted upon.

The introduction of Martha’s Rule should help give patients and their families greater confidence that, if they are genuinely concerned about a deterioration in someone’s condition, there is another way to raise that concern and seek an urgent review.

From a medical negligence perspective, we regularly see the devastating consequences that can arise when symptoms are missed, diagnoses are delayed or deterioration is not recognised.

Martha’s Rule cannot prevent every medical error, but creating a culture where concerns are listened to and investigated can only be an important part of improving patient safety.”

Martha’s Rule does not mean every medical mistake is negligence

It is important not to confuse patient safety initiatives with the legal test for medical negligence.

Medicine is not an exact science.

Doctors can make reasonable decisions which, with the benefit of hindsight, turn out not to have produced the desired outcome.

A patient becoming seriously ill after attending A&E does not automatically mean that someone was negligent.

However, where there are concerns about the assessment, diagnosis, investigation, treatment or monitoring provided, the medical records can be examined to determine what happened.

This may include looking at:

• A&E records;
• triage records;
• ambulance records;
• nursing observations;
• blood test results;
• imaging;
• clinical notes;
• prescriptions;
• discharge records;
• subsequent hospital treatment; and
• GP records.

Independent medical experts may then be required to consider whether the treatment provided was reasonable and whether a different approach would probably have resulted in a better outcome.

What if you believe your concerns were ignored?

If you or a family member attended A&E and you believe that serious concerns about a patient’s condition were not properly addressed, it may be appropriate to seek specialist advice.

This does not necessarily mean that you have a medical negligence claim.

However, if a patient subsequently suffered a serious injury, deterioration or worsening of their condition, it may be important to establish exactly what happened.

In some cases, the medical records may reveal that warning signs were present but were not acted upon. In others, the records may show that the treatment provided was reasonable despite the eventual outcome. The important thing is to establish the facts.

The Aston Knight Difference

At Aston Knight Solicitors, we specialise in complex and rejected personal injury and medical negligence claims.

Medical negligence cases can be complicated. A patient may know that something went wrong but not understand why. The medical records can be extensive and difficult to interpret.

Different doctors may have been involved. There may be conflicting accounts of what happened.

In some cases, another firm may have decided that a claim was too difficult to pursue.

Our approach is to investigate the evidence carefully.

We consider what happened, what should have happened, whether the appropriate standard of care was provided and whether any failure caused avoidable injury.

Martha’s Rule is intended to give patients and their families another way to speak up when they are concerned.

Patients should never be afraid to ask questions about their care.

And where something has gone seriously wrong, patients and families deserve to understand what happened.

Frequently Asked Questions

Does Martha’s Rule apply to A&E?

Yes. From September 2026, Martha’s Rule is being extended to A&E departments across England. The rollout is being phased and is expected to be completed by March 2028.

Can I ask for a second opinion under Martha’s Rule?

If you or your family are seriously concerned that a patient’s condition is deteriorating and your concerns are not being adequately addressed, Martha’s Rule provides a mechanism for requesting an urgent clinical review.

Does Martha’s Rule mean my doctor has been negligent?

No. Requesting a review does not mean that negligence has occurred. It is a patient safety mechanism designed to identify and respond to deterioration.

What if my concerns were ignored and the patient was seriously injured?

If you believe that concerns about a patient’s deterioration were not properly addressed and the patient subsequently suffered avoidable harm, it may be appropriate to obtain specialist legal advice. The medical records and independent medical evidence may be important in determining whether there was negligence.

Does Martha’s Rule apply in Wales?

The announcement on 22 September 2026 concerns the rollout across England. The position in Wales is separate, and Martha’s Rule has been the subject of ongoing discussion there.

If you believe something went wrong in A&E

Martha’s Rule is about giving patients and families a voice when they are concerned that someone’s condition is deteriorating.
That principle is important.

If you or someone close to you has suffered serious injury following treatment in A&E, particularly where you believe symptoms were missed, a diagnosis was delayed, treatment was not provided appropriately or concerns about deterioration were not acted upon, specialist advice may be appropriate.

Contact Aston Knight Solicitors today to discuss your circumstances.