Healthcare is a field where trust, timely action, and accountability is critical.

In recent years, patient safety has taken centre stage in the UK, with systemic reforms designed to prevent avoidable harm and empower patients, families, and healthcare staff to act when concerns arise.

Among the most significant developments is Martha’s Rule, a patient safety initiative now fully implemented in all 210 acute hospitals across England.

What is Martha’s Rule?

Martha’s Rule was introduced following the tragic death of 13-year-old Martha Mills from sepsis in 2021. The rule allows patients, carers, families, or NHS staff to request an independent review when there are concerns that a patient’s condition is deteriorating or that care has not met expected safety standards. Its aim is to ensure that concerns are escalated promptly and acted upon before serious harm occurs.

Since its nationwide rollout, Martha’s Rule has led to 241 confirmed life-saving interventions from nearly 5,000 calls received. These figures highlight the critical importance of giving every voice the power to trigger independent oversight in patient care.

The shift to the patient safety incident response framework

Alongside Martha’s Rule, the NHS has transitioned from the Serious Incident Framework (SIF) to the Patient Safety Incident Response Framework (PSIRF). This change reflects a shift towards:

  • System-wide learning: Investigations now focus on understanding how incidents occur rather than attributing blame solely to individuals.
  • Inclusive engagement: Patients and families are now active participants in investigations, ensuring their perspectives inform safety improvements.
  • Continuous improvement: Lessons learned are embedded across care systems to prevent future harm.

While PSIRF represents a step forward in promoting a learning culture, it also introduces challenges. Families and staff may feel their concerns are not fully addressed if investigations are perceived as procedural rather than meaningful. It is crucial that implementation balances learning, accountability, and compassion.

TMLEP’s role in patient safety investigations

At TMLEP, we provide guidance, support, and oversight to healthcare organisations navigating patient safety investigations. Our work ensures that:

  • Investigations are thorough and transparent: Every incident is examined with attention to both systemic factors and individual responsibilities.
  • Patient and family engagement is meaningful: We prioritise inclusive communication so that those affected feel heard and supported.
  • Learning drives action: Insights from investigations are translated into policy updates, staff training, and improvements in care delivery.

Our goal is to foster a culture where patient safety is everyone’s responsibility, and where the lessons learned from each incident prevent harm in the future.

Challenges and opportunities ahead

While Martha’s Rule and the PSIRF are promising, patient safety remains a complex and evolving field. Some ongoing concerns include:

  • Ensuring timely and consistent reporting across hospitals.
  • Addressing potential resistance from staff accustomed to traditional investigative models.
  • Integrating electronic health records and digital systems safely to prevent technical errors.

TMLEP is committed to addressing these challenges by supporting best practices, offering investigative expertise, and promoting transparency. We believe that a strong, responsive patient safety framework not only prevents harm but also reinforces public trust in the healthcare system.

Looking Forward

The implementation of Martha’s Rule is a landmark moment for patient safety in the NHS. It demonstrates a commitment to listening to patients and families, acting decisively to prevent harm, and fostering a culture of accountability.

At TMLEP, we remain dedicated to enhancing investigative practices, supporting healthcare professionals, and advocating for systems that place patient safety at the heart of every decision. Together, with continued vigilance and collaboration, we can make the NHS safer for everyone.

​​For more information on TMLEP’s services, click here.