The rule is now national
A new rule is in effect. It is called Martha’s Rule. From today, 22 September 2026, the system is mandatory for every accident and emergency department within the National Health Service in England. The change is significant. It formalises the right to a second medical opinion for anyone who is concerned about a patient's condition. The process is clear. The right is explicit.
Health officials announced the national expansion. The rule gives patients, their loved ones and even NHS staff a direct route to request an urgent review of care from a separate team of doctors. This is a fundamental shift. It provides a structured process for escalating concerns when someone feels they are not being listened to by the clinicians immediately responsible for their treatment. The system is designed to be straightforward. The review is conducted by a different medical team. That team examines the care being provided and can recommend changes.
Anyone can trigger it. A patient in an A&E cubicle can use the rule. A family member at a bedside can use it. The sources confirm that health workers themselves can also activate the process if they disagree with the care being provided by colleagues. This gives patients a voice. It gives their families a voice. It also gives junior hospital staff a formal mechanism to challenge a clinical decision made by a senior. Before this, no such recognised pathway existed for patients or their relatives in such a direct way.
The decision to extend the rule to every A&E department follows an earlier rollout across 143 hospital trusts. This is the next stage. Its implementation in the fast paced, often chaotic environment of an emergency department marks a new phase for the policy. It is no longer a pilot project confined to inpatient wards. It is now a standard feature of emergency care everywhere in the country. The posters are up. The phone numbers are active. The system is live.
It is named after Martha Mills
The rule is named for Martha Mills. She died in 2021. She was thirteen.
Her death followed an accident on her bicycle, an event which caused a serious injury to her pancreas and resulted in her admission to hospital. She developed sepsis while in care. Her parents, Merope Mills and Paul Laity, were with her. They believed her condition was deteriorating. They expressed this belief to the clinical staff responsible for Martha's treatment on multiple occasions.
The family's observations were not listened to. Their direct and repeated warnings about the visible decline in their daughter’s health were dismissed by the medical team. They were ignored. This failure to act on parental concern is the specific event that Martha's Rule is designed to prevent from happening again within an NHS hospital in England. Merope Mills and Paul Laity argued that their daughter was visibly worsening, but they found themselves without any formal power to demand a review from a different set of doctors.
Martha's case became a national campaign. Her parents have since spoken publicly about the experience. They described a hospital culture where their legitimate fears, based on moment by moment observation of their own child, were overruled by clinicians. The campaign focused on establishing a clear, official and non confrontational way for a patient or their family to get a second opinion. Quickly. Simply. The objective was to create a safety mechanism for situations where communication between a medical team and a family has broken down.
The story of what happened to Martha Mills galvanised support from politicians and the leadership of the National Health Service. The core problem was identified not as a simple medical error, but as a failure of communication and a power imbalance between doctors and patients' families. Her parents argued that if a system had existed for them to trigger an urgent clinical review from a fresh team of medics, Martha's sepsis would have been identified and treated. She might have lived. The new rule is the direct result of their campaign following her death.
How a review is triggered
The process is designed for simplicity. It is meant to be used under stress. A person, whether a patient or a relative, who feels their concerns about a worsening condition are not being heard can now act. They see posters. These signs will be displayed in wards and emergency departments, advertising the system and providing a dedicated 24/7 phone number for people to call. The person with the concern simply needs to call that number or alert a staff member, who can then make the call for them. The activation is straightforward. It is immediate. This initial step triggers a formal, rapid review of the patient’s care from a completely fresh team of clinicians.
That review must be conducted by a critical care outreach team, known as a CCOT. The patient's existing medical team is not part of this urgent assessment. This separation is fundamental. It ensures a genuinely independent second opinion is brought to the bedside without the need for confrontation between a family and the doctors already providing care. CCOTs are mobile specialists. Their job is to bring critical care expertise out of the ICU and onto the general wards. They are experts in spotting and managing acutely unwell patients whose health may be declining. These teams already exist within the NHS.
Critical care outreach teams are typically staffed by senior nurses with a background in intensive care medicine, and they often include doctors or advanced practitioners from the same specialism. Their traditional role is to support ward staff by reviewing patients they are worried about, helping to prevent avoidable cardiac arrests or admissions to the intensive care unit by intervening early. Martha’s Rule formalises their function as the designated second opinion service, giving them a clear mandate to respond when alerted directly by patients or their families. They are the safety net. Fresh eyes.
The CCOT will attend the bedside to conduct a full assessment of the patient. They review the medical notes, check vital signs and speak directly to the patient and their family to understand the specific worries that led to the activation. After this comprehensive evaluation, the team provides objective advice and can make recommendations, which might include altering treatment, ordering new tests, or escalating the patient's care to a higher dependency ward. The process creates an official channel for concerns to be heard and professionally evaluated. It bypasses hospital hierarchy. It gives patients power.
The results from the first 143 hospitals
The rule's journey was methodical. It began with a trial. The pilot started in April 2024. It involved 143 hospital trusts across England, providing the first real world test of the system designed to give patients a voice and a formal route to a second opinion. This initial phase focused on gathering data on how the system was used, how often it was activated, and what the outcomes of the resulting clinical reviews were. The government and NHS England needed to see if the concept could work in practice before committing to a national expansion. They needed evidence. The pilot provided it.
After the trial came the headline claim. Health officials announced the results. Official figures, they said, showed the rule had already potentially saved hundreds of lives. That is a significant number. The claim is based on data collected from those first 143 hospitals. The precise methodology for calculating this figure has not been released for public scrutiny, and the word 'potentially' carries a great deal of weight in the official statements. It suggests an estimate based on clinical judgements where an intervention was deemed to have prevented a catastrophic decline, rather than a simple count of near misses. The claim is bold. The details are not.
The positive assessment, headlined by the life saving statistic, was the catalyst for the policy's expansion. The pilot was judged a success. A success great enough to justify this next step. The decision was then made to widen the scheme to cover every single acute hospital in the country, beginning with the most pressurised and complex environment of all, the accident and emergency department. This progression from a limited trial on wards to a universal application in A&E represents a huge acceleration for the policy, moving it from a controlled experiment to a fundamental component of urgent care nationwide. It is a major change.
The initial pilot sites provided a controlled environment. They were mostly inpatient wards. Transplanting the system into the organised chaos of an A&E presents a different order of challenge entirely. The data from the first 143 trusts was deemed sufficient justification for expansion, yet the environment where that data was gathered is not the same as the one it now enters. Success must be replicated. It must be replicated against a backdrop of shorter patient stays, faster decision making, and immense operational pressure. The claim of saving hundreds of lives on hospital wards will now be tested anew in the emergency department. The metrics will change. Time is different here.
A change in hospital power structures
The rule is for health workers too. Not just for patients. This element of the system has the potential to alter the internal power structures of the National Health Service, moving beyond patient rights and into the professional hierarchy of the hospital itself. A hospital is a pyramid. At the top sits the consultant, whose clinical judgement is the final word. Below them are registrars, junior doctors and nurses, all operating within a clear and rigid chain of command. Martha's Rule inserts a new process into this structure, providing a formal, sanctioned mechanism for a junior member of staff to request an urgent second opinion on a patient's care. It bypasses their direct superiors. This is a deliberate change.
This offers a junior doctor or a nurse a tool they have never had before. They are often the staff who spend the most time with a patient. They observe their condition continuously. They may be the first to notice a subtle deterioration that a more senior doctor, who sees the patient for only a few minutes on a ward round, might miss. In the past, raising such a concern against the opinion of a consultant could be a career limiting act, reliant on personal courage and the hope that the senior clinician would be receptive. This rule changes the dynamic. It reframes a challenge from an act of insubordination into an act of patient safety. The request for a review is not a personal criticism. It is the activation of an agreed safety protocol. It is a systemic backstop.
The question is whether it will be used. The cultural barriers to a junior clinician formally questioning their boss’s judgement are immense, and the existence of a new phone number on a poster will not dismantle them overnight. Will staff use it? There is a risk that senior staff could view the use of the rule as a vote of no confidence in their abilities, which might create a climate where junior staff still feel unable to trigger it for fear of informal repercussions. Its success depends entirely on whether NHS trusts can foster a genuine no blame culture, one where a challenge is seen as a strength of the system, not a weakness of the individual clinician being challenged. The policy offers a path. It does not guarantee anyone will walk down it. The true test will be how the hospital hierarchy reacts not to the rule itself, but to the first person on the team who dares to use it.
What to watch for in the emergency department
An emergency department is chaos. It is not a ward. The principles of Martha's Rule are sound, but the speed of A&E presents a unique test of its design and its limits. The core challenge is time, because the system was conceived for the relative stillness of an inpatient ward where a patient might stay for days, whereas an A&E department operates under the pressure of a national four hour waiting target. This changes everything. Can it work?
A review is triggered by a call. A critical care outreach team, separate from the patient’s own doctors, must then conduct an assessment. On a Tuesday night at a major trauma centre like St George's Hospital in Tooting, with dozens of patients waiting for beds and ambulances queued outside, assembling that second team quickly enough to make a difference without causing systemic delays elsewhere will be a serious operational challenge. Staff are already stretched. Resources are finite. The national rollout from 22 September 2026 follows a pilot in 143 trusts that began in April 2024, but this trial took place primarily on inpatient wards. There is little data on how the rule functions in the frenetic, high turnover environment of an emergency room, where a patient may be disoriented, in severe pain, and present for only a few hours.
Success or failure will be measured in new ways. One key metric will be the official A&E waiting time statistics published monthly by NHS England. The government target is for 76 per cent of patients to be admitted, transferred or discharged within four hours. If that average wait lengthens and trusts cite reviews under Martha's Rule as a contributing factor, the system will face intense scrutiny. Another measure is uptake. If the number of requests is very low, it may suggest patients and junior staff do not feel able to use it. If it is very high, it could overwhelm the critical care teams tasked with responding.
The ultimate measure is the most difficult one. It is whether avoidable deaths and serious harm incidents in A&E decrease over the next year. This data is slow to emerge and hard to attribute to a single policy. The first signs of strain will appear much sooner, in the waiting time figures and in reports from exhausted staff on the ground. The system is designed to save lives. Its first trial is whether it can survive contact with the reality of an NHS emergency department on a winter night.
Sources. BBC News Health: Martha's Rule rolled out at every A&E department in England. Guardian UK: Martha’s rule to be expanded to every A&E in England.
Analysis. Drafted with AI assistance from the sources listed above and reviewed by an editor before publication. Jnews links to the organisations it writes about.
