Martha's Rule and escalating deterioration: what every inpatient nurse needs to know

Cue 1 A timeline of Martha's illness with the repeated concerns of her family marked and the delay highlighted

EMMA 00:00 George, Martha's Rule. I know it's a big deal but I've never been told what it actually says. Start from the start?

GEORGE 00:08 I'll start with Martha. Martha Mills was thirteen. She died in 2021 of sepsis after an injury to her pancreas. The inquest in 2023 found she would probably have survived if she'd been moved to intensive care sooner. And her parents had said, repeatedly, that they were worried she was getting worse.

EMMA 00:29 And nobody acted.

GEORGE 00:30 Not quickly enough. That's the finding. The principle that came out of it is simple. The people who know a patient best see them when we're not at the bedside, and they can notice deterioration before a chart does. There has to be a way for that to be heard.

Cue 2 Three cards for the three components with a different team arrow on the second

EMMA 00:50 So what is the rule?

GEORGE 00:52 Three parts, in NHS England's words. Patients are asked at least daily how they're feeling and whether they're getting better or worse. All staff can, at any time, ask for a review from a different team if they're concerned. And that route is always open to patients, families and carers.

EMMA 01:12 A different team. Why does that matter?

GEORGE 01:15 Because the point is fresh eyes. Not the same team asked the same question twice. If you've been told it's fine and you still don't think it is, you need a way past that.

Cue 3 A hospital ward with its dedicated phone number on the wall and a family member holding a phone

EMMA 01:29 How does somebody actually call?

GEORGE 01:31 Each hospital has its own dedicated phone line. There's no single national number. It should be given to patients and visible on the ward. Do you know yours?

EMMA 01:42 ...No. Not off the top of my head.

GEORGE 01:45 Then a frightened relative doesn't either. Learn it, and know where it's displayed. That's your first job.

Cue 4 A bar showing most deterioration calls sitting outside what the early warning score alone would have escalated

EMMA 01:52 Is every hospital doing this?

GEORGE 01:54 NHS England says all acute trusts must have the three core components in place in adult and paediatric inpatient settings by 31 March 2027. Many already run it in some or all areas, and they reported over 10,000 calls by March 2026.

EMMA 02:11 Doesn't NEWS2 do all this already? That's what the early warning score is for.

GEORGE 02:16 It does a lot. But NHS England reports that most acute deterioration calls, 82 per cent in the data they cite, wouldn't have triggered escalation through early warning scores alone.

Cue 5 A worried relative at the bedside, a nurse listening, checking the patient and recording the concern

EMMA 02:28 Eighty two per cent? So most of the worry wasn't on the chart.

GEORGE 02:33 Right. That doesn't make scores unreliable. They answer one question, what do the numbers say. Martha's Rule answers another, what do the people who know this patient think. You need both.

EMMA 02:46 What do I say when a relative rings the line, or says they're worried at the bedside?

GEORGE 02:53 What you do with your face and your first sentence matters most. A defensive reply, the observations are fine, teaches them not to say anything again.

EMMA 03:03 So what instead?

GEORGE 03:04 Thank them. Ask what they've noticed, in their words, and since when. Check the patient yourself. Tell them what you'll do and by when, then do it. If the line's the right route, help them use it.

EMMA 03:19 And if I think they're wrong?

GEORGE 03:22 Check anyway. Treat a family's worry as clinical information, not as a complaint. A worried relative told they're wrong, on the day they're right, is how an inquest begins.

Cue 1 Six parameter gauges feeding a total, with two extra points for oxygen

EMMA 03:33 George, I take observations all day. But if I'm honest, I'm never fully sure what to do with the number once I've got it. Walk me through NEWS2.

GEORGE 03:44 Six parameters. Respiration rate, oxygen saturation, systolic blood pressure, pulse, level of consciousness or new confusion, and temperature. Each is scored, and you add two points for anyone who needs oxygen to keep their saturation at the recommended level.

EMMA 04:00 New confusion is the one I always wonder about.

GEORGE 04:04 It's the one that's missed most. Someone orientated yesterday who's muddled today has changed, whatever their other numbers say. Score it and say it out loud.

Cue 2 A table of the four risk bands with the single parameter of three highlighted

EMMA 04:14 And the totals?

GEORGE 04:15 Four bands. Zero to four is low risk, usually continued monitoring and a registered nurse decides how often. A single parameter scoring three, the most extreme for that measurement, is low to medium and needs an urgent ward-based response even if the total is low.

EMMA 04:33 Even with a low total?

GEORGE 04:35 Yes, because the total can hide one very abnormal number. Five or six is medium, the key threshold for an urgent response by a clinician competent in acute illness. Seven or more is high, and that's an urgent or emergency response from a team with critical care skills.

Cue 3 A patient with normal numbers but a worried daughter, with soft signs listed beside

EMMA 04:54 Is that the same in every hospital?

GEORGE 04:57 Follow your trust's chart and escalation policy. It can differ in detail. There's also a second saturation scale a clinician may decide to use for someone with confirmed hypercapnic respiratory failure. That's a clinician's decision. Not a healthcare assistant's, not a student's.

EMMA 05:14 What about when the score's fine and something still feels wrong?

GEORGE 05:18 That's exactly Martha's Rule's territory. The score tells you what the numbers say now. It doesn't tell you they've gone quiet, or look grey, or that their daughter's frightened.

Cue 4 SBAR as four stacked cards with a specific timed request on the last one

EMMA 05:30 What are the soft signs?

GEORGE 05:32 A change in behaviour. New drowsiness or agitation. Not eating or drinking. Not passing urine. A change in colour. And a feeling that something's wrong, which counts. Say that feeling out loud when you escalate.

EMMA 05:46 I get tongue tied when I phone a doctor. Is there a structure?

GEORGE 05:51 SBAR. Situation, who you are, where, who the patient is, what's wrong now. Background, why they're here and what matters. Assessment, your observations, the score, what you think is happening and how worried you are. Recommendation, what you want and by when.

Cue 5 A chain of escalation steps going up, with a record entry at each step and the Code clauses 13.2 and 17.1

EMMA 06:08 The last bit's the one I skip.

GEORGE 06:11 Everybody does, and it's the most important. I would like you to review him within fifteen minutes is a request. Can you have a look at some point is not. Be specific.

EMMA 06:24 And if they say they're coming and they don't?

GEORGE 06:27 Escalate again, to the next level, and say why. If the response doesn't match your concern, that's the point of the Martha's Rule line. Nobody should be criticised for using it in good faith.

EMMA 06:41 What do I write down?

GEORGE 06:43 What you found, the score, who you escalated to, when, what they said, what happened. A family member's concern, in their words, and what you did about it. Clause 13.2 asks for timely referral. Clause 10.1 for records at the time or as soon as possible.

EMMA 07:01 And the one that scares me. Going over someone's head.

GEORGE 07:05 Clause 17.1. Take all reasonable steps to protect people at risk of harm. Escalating again is a reasonable step. Stopping at the first no may not be. You'd rather explain why you called than why you didn't.