The Nurses Who Answer Martha’s Rule Now Cover A&E

NHS England is expanding Martha’s Rule to every A&E department and waiting room in England, with the work due to finish by March 2028. Patients, relatives and staff will get a dedicated number to force a fresh look when someone is getting worse and they think nobody is listening.

The people who then walk to the trolley are critical care outreach nurses, and the A&E test ran without extra clinical staff.

The Team That Walks to the Bedside

Martha’s Rule is named after Martha Mills, who died in 2021 aged 13 at King’s College Hospital in London. She had been admitted after a cycling fall that injured her pancreas. She later developed sepsis. A coroner ruled in 2022 that she would probably have survived if she had been moved sooner to intensive care.

Her parents, Merope Mills and Paul Laity, pushed for a route that does not stop at the ward team. When the number is dialled, the point is not a complaint desk. It is a clinician who does not already own the case.

Prof Aidan Fowler, national director of patient safety at NHS England, said a call should bring an “appropriate response”, such as a senior nurse or a member of the critical care outreach team reviewing the patient. Staff can also ask a different team to look, if they think the right action is not being taken.

That second look is the whole machine. At Rotherham Hospital, Call 4 Concern, the local name for the same idea, is answered by the Acute Response Team, advanced practitioners and specialist nurses who treat very sick patients. After a call, the Acute Response Team will visit the ward, talk through the worry, and examine the patient if needed.

Mid Yorkshire hospitals already run a similar 24-hour deteriorating-adult team that covers wards, the emergency department, same-day emergency care and urgent treatment centres. The A&E expansion does not invent that workforce. It asks the same nurses to cover trolleys and waiting-room chairs as well as beds.

NHS England said the A&E pilot, run between September 2025 and March 2026 at seven trusts, could sit beside existing procedures without extra clinical staff. Fowler said people had used the line “very sensibly” through winter and a busy summer, and that he was not concerned the service would be overwhelmed.

The already stretched rapid response teams should not be expected to bear the brunt of providing a 24/7 safety net.

Professor Nitin Kapur, paediatric respiratory physician, Queensland Children’s Hospital, writing for the Royal College of Paediatrics and Child Health

Kapur, who is president of the paediatric division of the Royal Australasian College of Physicians, was writing about Queensland’s older scheme, which England copied in outline. His warning still lands on the English rollout, because the people who pick up are the same kind of team.

Families Place Most of the Calls

NHS England recorded 19,177 Martha’s Rule calls from September 2024 to July 2026. July 2026 was the busiest month so far, at 1,678. 72% of calls came through the family and carer route. 5,660 calls, 30%, were about acute decline. Of those, 3,432 led to a change in treatment, including 749 moves to a higher level of care, a specialist hospital, or a specialist ward. A further 4,940 calls helped with communication and discharge planning.

The A&E trial is tiny beside that. Across eight months at seven trusts, dedicated numbers took 69 calls. Some of those patients went for urgent surgery or to intensive care. Fowler said the count might look small, and that the decision to go further rested on long experience on the wards, not on A&E volume alone.

A fuller split exists only through December 2025, when the programme had taken 10,119 calls. Staff were a small slice of callers, and a large slice of the true alarms.

WHO CALLED THROUGH DECEMBER 2025

Staff still need the line. When they used it in that period, 61% of their calls were about a patient who was actually getting worse, against 31% of family calls. Junior nurses and doctors are supposed to be able to go around a hierarchy that is not moving. Most of the traffic, even so, still comes from relatives who already know the patient’s face, voice and baseline.

Elliott Paterson, from Cheltenham, said the rule saved his 67-year-old father, Chris, at Gloucester Royal Hospital after Chris broke four ribs falling off a bike. Treatment on the surgical ward was harder because of Addison’s disease, a rare condition of the adrenal glands. The family saw him decline, called the critical care team, and that team treated both the injuries and the Addison’s.

“To hear that Martha’s Rule is now to be rolled out across the NHS is brilliant news and I hope that for more people it will continue to save lives,” Paterson said. “I am incredibly fortunate and grateful to have had Martha’s Rule at our disposal at the time.”

In A&E, the Daily Question Falls Away

On a ward, Martha’s Rule is three jobs at once. Patients are asked, at least daily, whether they feel better or worse, and that answer is written down and acted on. Staff can call a different team at any hour. Patients, families and carers get the same route, advertised on posters and leaflets.

A waiting room has no named nurse for the day, no drug chart, and no morning question. People sit with pain, fever, missed tablets and a number on a wall. NHS England called the move into waiting rooms a landmark for that reason. It is also the part that does not copy the ward script.

The announcement on 22 September 2026 came after what NHS England said was the busiest summer in the health service’s history, with 241,061 more A&E attendances in June, July and August 2026 than in the same months of 2025. The phased roll-out due by March 2028 therefore lands on departments that are already running hot, 18 months after the start gun.

A missed Parkinson’s dose in that queue can look like confusion, stiffness or a sudden slump, not like a tablet that was due two hours ago. Parkinson’s UK made that point as the A&E news broke, telling people that if timed drugs stop, they need help at once. Scores built for admitted patients will not see that. A relative who knows the usual morning self might.

Actor Jason Watkins, whose daughter Maude died of sepsis in 2011 aged two and a half, backed the A&E step and said the rule was already changing how wards work. He urged anyone who is worried in emergency care to ask for a second opinion, and said it also gives doctors and nurses a pause to ask whether they have assessed a child as fully as they can.

Health minister Baroness Merron said the expansion sits inside a wider push to put patient safety at the heart of the NHS, and that it gives patients, families and staff another way to speak up when they think someone is getting worse.

Queensland Already Covers Emergency Departments

England did not design this from a blank page. Queensland Health built the Ryan’s Rule three-step process after Ryan Saunders died in 2007, aged nearly three, from an undiagnosed streptococcal infection that led to toxic shock. His parents felt their alarms were not acted on in time. The rule, launched in 2013, applies to patients in Queensland public hospitals, including emergency departments.

The UK’s Patient Safety Commissioner has called Ryan’s Rule the forerunner of Martha’s Rule. Call 4 Concern, first tried in English hospitals around 2010, is the other parent. Wales is rolling out Call4Concern rather than the English brand. Scotland has started to use Martha’s Rule. Northern Ireland is considering it.

Queensland’s record is the longest public test of what a family phone line actually does, and who should answer it.

WHAT ELEVEN YEARS OF RYAN’S RULE SHOWED

• Volume stayed modest: 13,977 activations in 11 years, averaging three to four calls a day, though 2023 alone saw 2,355, about seven a day.
• Most calls are not a crash: 52% led to no change in planned care, and about 60% turned on communication, including a sense that decline was being missed.
• Urgent rescue is rare: 199 calls, 2.7%, led to urgent escalation of care.
• Crash teams were the wrong default: once it was clear that a full medical emergency team was a poor use of people for most calls, many hospitals switched to a dedicated Ryan’s Rule group, often a safety nurse and a senior junior doctor.
• Staff still hear a complaint: in a small sample of 57 clinicians, professionals tended to treat an activation as a complaint, while families treated it as a concern.

Kapur noted that England’s staff-led route is a real difference, and that early English pilots produced a higher share of urgent step-ups than Queensland. He also said vision without execution is hallucination, and that stretched rapid response teams should not be left holding a round-the-clock net on their own. Queensland learned that by trying it, then changing who walks to the bed.

How Do You Trigger a Review in A&E?

Until your local trust finishes the A&E step, the number is not everywhere. Check the trust website or ask staff whether Martha’s Rule is live in that department. If it is, posters and leaflets should carry a 24-hour line. You do not need a diagnosis. You need a clear sense that the patient is getting worse and that the team in front of you has not taken that seriously.

THE THREE PARTS OF MARTHA’S RULE

• The daily question: patients are asked, at least once a day, whether they feel better or worse, and staff must act on the answer in a set way. That piece fits a ward. It does not yet have a natural home in a waiting room.
• The staff route: any member of staff can ask a different team to review a patient whose decline is being ignored, including staff who would otherwise have to go up their own chain.
• The family number: patients, families and carers can call the same route, which must be advertised around the hospital, and which in A&E will also be offered in waiting rooms.

In practice the call is short. You give the patient’s name, where they are in the department, and what has changed. The operator’s job is to send someone who is not the original team. Fowler’s example was a senior nurse or an outreach clinician. The review can mean new drugs, a move to a monitored bay, surgery, or a conversation that lowers the temperature if the worry is real but the treatment plan already matches it.

Trusts have been told, in NHS England’s core standards, that reviewers must be independent of the patient’s ongoing care, skilled enough to judge decline, and able either to do the review or to get the right clinician there fast. Equity of access is on the same list, because Queensland found early on that people who do not speak English as a first language, and First Nations families, used the line less until materials were rewritten.

Wards Must Comply by 31 March 2027

The A&E date is not the only clock. Martha’s Rule is already going into the NHS Standard Contract. Service Condition 33.13 tells every NHS trust and foundation trust to put the three core parts in place for adult and child inpatient services by 31 March 2027. In the contract consultation, 97% of respondents backed that deadline. Mental health trusts are still in testing, and the duty does not yet run beyond NHS trusts.

NHS England says the rule is now live at 221 acute adult and paediatric inpatient sites, with the rest of those wards due during 2026/27. Phase 1 put it into 143 sites between September 2024 and March 2025. In June 2026, after Donna Ockenden’s maternity review at Nottingham, trusts were told to extend it to maternity and neonatal units as well, with that work, like A&E, aimed at March 2028.

HOW THE RULE MOVED FROM ONE WARD TO A&E

1. 2021: Martha Mills dies aged 13 at King’s College Hospital after sepsis is not treated in time.
2. 2022: A coroner finds she would probably have survived with earlier intensive care.
3. September 2024: Phase 1 begins at 143 acute sites.
4. April 2025: Phase 2 starts, pulling in remaining adult and child inpatient services.
5. September 2025 to March 2026: Seven trusts test the phone line in A&E; 69 calls are logged.
6. 2 March 2026: NHS England publishes core standards for safe rollout.
7. 31 March 2027: Standard Contract deadline for the three parts on inpatient wards.
8. March 2028: Hospitals are expected to have extended the rule to A&E, maternity and neonatal units.

Patients who need the line before those dates still have to ask. NHS England’s own programme page says hospitals are at different stages, and that in some places the rule may only run on certain wards. The A&E expansion starts now and finishes, if the plan holds, in March 2028.

Relatives Catch What the Score Misses

The strongest number in the ward data is not the raw call count. Between June 2025 and July 2026, 82% of Martha’s Rule calls about acute decline would not have triggered escalation on the early warning score. Families and staff were seeing a change the chart had not yet labelled as an emergency.

THE WARD RECORD BEHIND THE A&E BET

• 19,177 calls: logged from September 2024 to July 2026, before A&E is even fully in scope.
• 72% family: most alerts still come from people who know the patient, not from the rostered team.
• 82% below the score: most decline calls in the year to July 2026 would not have tripped the official trigger.
• 69 A&E calls: the emergency pilot stayed small, which is why the workforce argument, not the volume argument, decides whether waiting rooms can copy the wards.

That is the bet hidden inside a family-rights story. Outreach teams already absorb thousands of reviews that the score would have missed, and three-quarters of those requests come from relatives. A&E waiting rooms strip out the daily question and leave the phone. NHS England says the seven-trust test did not need extra clinicians. Queensland says a crash team is the wrong default for a line that is often about being heard. Until March 2028, the only reliable step is the unglamorous one: ask the trust in front of you whether the number on the wall is live, and whether someone independent will actually walk over when it rings.

Disclaimer: This article is news reporting and analysis of NHS England’s Martha’s Rule expansion, and it is for information only. It is not medical advice, a diagnosis, or a guide to any one patient’s care, and it does not tell you whether to seek emergency treatment. If you are worried about yourself or someone else in hospital, speak to the clinical team on the spot and, where the service exists, use that hospital’s own Martha’s Rule or Call 4 Concern number; for personal medical decisions, consult a doctor or nurse who can see the patient. Call counts, site lists and rollout dates reflect NHS England and hospital figures as published around 22 September 2026 and may change as trusts complete the phased programme.