Managing Deterioration and Martha's Rule

Managing Deteriorating Patients

Preventing deterioration associated harm is a key aim of the NHS Patient Safety Strategy, focussing on implementation of the ‘PIER approach’ and Martha’s rule.

Managing acute physical deterioration through the ‘Prevention, Identification, Escalation, Response’ (PIER) approach 

The new PIER approach facilitates safer and more effective management of acute physical deterioration in health and care. It applies to all clinical settings, specialities, and conditions, and views deterioration as a whole pathway supported by systems, as opposed to a single identification strategy. 

PIER stands for:

• Prevention: planning ahead of any episode of deterioration to stop what is preventable, considering indicators of risk and patient choice.
• Identification: tools and methods to identify when deterioration is occurring in a standardised way.
• Escalation: timely escalation of care when deterioration has been identified using standardised communication tools.
• Response: timely, appropriate and effective response to escalation of the deteriorating patient/person.

Martha’s Rule

The purpose of Martha’s Rule is to provide a consistent and understandable way for patients and families to seek an urgent review if their or their loved one’s condition deteriorates, and they are concerned this is not being responded to.

Martha Mills died in 2021 after developing sepsis in hospital. Martha had been admitted with a pancreatic injury after falling off her bike whilst on holiday. Martha’s family concerns about her deteriorating condition were not responded to on several occasions and in 2023 a coroner ruled that Martha would probably have survived had she been moved to intensive care earlier.

In response to this and other cases related to the management of deterioration, the Secretary of State for Health and Social Care and NHS England committed to implement ‘Martha’s Rule’; to ensure the vitally important concerns of the patient and those who know the patient best are listened to and acted upon.

In April 2024, national implementation of Martha’s Rule began. Once NHS hospitals have fully implemented all components, patients, families, carers, and staff will have round-the-clock access to a rapid review from a separate care team if they are worried about someone’s condition.

Martha's Rule has three components:

NHS England announced in May 2024 that 20 hospital sites in the South East, including the 7 acute Trusts in Wessex, will be rolling out Martha's Rule. Health Innovation Wessex will be working alongside these organisations to support implementation, innovation, and adoption of Martha’s Rule. 

Martha’s mother, Merope Mills, has been active in supporting change. You can listen to her speaking on BBC Radio 4's Woman’s Hour, read Martha’s full story, and learn Merope’s thoughts on Martha’s Rule. 

To ensure effectiveness, Martha's Rule builds upon the new early warning system for staff treating children and will be implemented alongside PIER.

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