Martha’s Rule Reaches A&E Waiting Rooms Without Extra Staff

NHS England is expanding Martha’s Rule to every hospital 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 rapid review if someone is getting worse and they think nobody is listening. The 22 September 2026 announcement followed a seven-trust pilot that logged 69 calls, and it arrives after the busiest summer on the health service’s own figures, with 241,061 more A&E attendances in June, July and August than in 2025.

The headline is a family hotline. The design choice underneath is harder: a ward tool, run by existing critical care outreach teams and tested on inpatients, is being asked to work in the part of the hospital with no bed card, no daily round, and the longest waits.

The Phone Line Is Coming to A&E Waiting Rooms

Until now the scheme has been built for people already admitted. NHS England said the new phase puts extra safeguards in waiting rooms if a patient starts to deteriorate while still in the department, covering all hospital A&E departments and waiting rooms in a phased programme. That is a different job from a ward, where a family can find a poster above a locker and a nurse who already knows the patient.

Martha’s Rule is to be expanded to A&Es across England.

Patients, loved ones and NHS staff will be able to call a dedicated number to request an urgent review if a patient’s condition is getting worse and they’re concerned it’s not being listened to.

➡️ https://t.co/ofwHKLtFyP pic.twitter.com/OT8rECQSUb

— NHS England (@NHSEngland) September 22, 2026

Professor Aidan Fowler, national director of patient safety at NHS England, called the move a “critical new lifeline” for patients, families and staff. Health minister Baroness Merron said it would give them “another way to speak up when they are worried that someone’s condition is getting worse.” Scotland is starting to use Martha’s Rule, Northern Ireland is considering it, and Wales already runs a similar scheme called Call4Concern.

The rule is named after Martha Mills, who died in 2021, aged 13, after developing sepsis at King’s College Hospital in London. She had been admitted with a pancreatic injury after a cycling fall. Her parents, Merope Mills and Paul Laity, said their concerns about her getting worse were not acted on. A coroner ruled in 2022 that she would probably have survived had she been moved to intensive care earlier.

WHAT WE KNOW

• The start: NHS England announced the nationwide A&E expansion on 22 September 2026, with completion due by March 2028.
• The test: An eight-month pilot at seven trusts, from September 2025 to March 2026, logged 69 calls and, NHS England said, needed no extra clinical staff.
• The wards: The scheme is already at 221 acute adult and paediatric inpatient sites, with that rollout due to finish in 2026/27.

WHAT IS UNCONFIRMED

• The seven trusts: NHS England has not named the emergency departments in the pilot.
• Waiting-room logistics: There is no national script yet for how a caller in a queue identifies a patient who has no ward or bed number.
• Night cover: How every department will staff a 24-hour outreach response through the phased years has not been set out in public.

A retired ward sister put the practical snag in plain terms: a waiting-room safety net that depends on a mobile phone also depends on battery and reception. The number only works if the person holding it can get through, and if someone on the other end can find the patient in a crowded department.

69 Calls in Casualty, 19,177 on the Wards

NHS England is not pretending the emergency-department evidence is large. Fowler said the 69 calls might look small and that the decision rests on “very, very extensive experience in other settings.” Between September 2024 and July 2026 the inpatient programme took 19,177 calls, with a record 1,678 in July 2026. Three quarters of the early ward traffic, and 72% in the latest cut, came from families and carers.

ED PILOT VERSUS WARD PROGRAMME

Of those 19,177 calls, 5,660 (30%) were about acute deterioration. Among that group, 3,432 needed a change in treatment, including 749 transfers to high dependency or intensive care, a higher level of care, a tertiary centre, or a specialist ward. A further 4,940 calls helped with communication and discharge planning rather than a crash in physiology.

Elliott Paterson, from Cheltenham, said he believes the rule saved his father Chris, 67, at Gloucester Royal Hospital in 2025 after a bike fall that broke four ribs. Chris also has Addison’s disease, and the family saw him worsen on the surgical ward, called the critical care team, and got both problems treated. “To hear that Martha’s Rule is now to be rolled out across the NHS is brilliant news,” Elliott said.

That is the ward version working as designed: a family that already knows the patient, a team that can walk to a bed, and time to notice a slide. Casualty is faster, noisier, and full of people who have not yet been given a named consultant, which is why 69 calls across seven trusts is a start, not a stress test of a record summer.

Why the Daily Check Stops at the Ward Door

Martha’s Rule is three duties, not one phone number. NHS England’s own description makes the mismatch with A&E obvious, because the first duty assumes someone is already in a bed long enough to be asked the same question every day.

THE THREE DUTIES

• The daily ask: Staff must take a structured account, at least daily, of how the patient feels and whether they are getting better or worse, and then act on it.
• The staff route: Any member of staff can, at any time, ask a different team for a review if they think a deteriorating patient is being ignored.
• The public route: Patients, families and carers get the same 24-hour review, advertised around the hospital, if they are worried and not being heard.

On a ward that bundle hangs together. The daily ask puts the family’s view into the notes. The posters tell them the number. Outreach already walks the building. In A&E the daily ask has nowhere to live. A patient on a trolley at 2am is not on a 24-hour observation chart in the same way, and a relative in the waiting room may not know which team holds the case.

Hospitals that already run the ward line show how tightly the call is built around an inpatient map. The Royal Marsden tells callers to have the patient’s name, ward and the concern ready, and says the outreach practitioner will come to the ward. That script does not copy cleanly onto a queue of people who have not been given a ward. The A&E expansion is, in practice, the third duty travelling alone, with the first duty left behind.

No Extra Staff for the Extra Line

NHS England said the pilot found the process could sit alongside existing clinical procedures “without requiring additional clinical staff.” The people who pick up are the critical care outreach teams already in the building, usually senior nurses, sometimes with a doctor on the loop. Fowler said a call should get an “appropriate response,” for example a senior nurse or an outreach clinician reviewing the case, and that staff can also ask a different team to look if they think the right action is not being taken.

A&Es see some of our most vulnerable patients, so the ability to raise concerns about deterioration quickly and trigger a rapid review of care is essential.

Professor Aidan Fowler, National Director of Patient Safety, NHS England

He also said the test ran through winter and a busy summer, that people “used it very sensibly,” and that he is not concerned the national rollout will swamp departments. That is a claim about call volume, not about who is left holding the bleep when a waiting-room call lands at the same moment as a ward crash.

Staff are already on the line. Between September 2024 and February 2026, 1,781 calls were made by hospital staff to trigger a rapid review, and 1,080 of those (61%) helped identify acute deterioration. Junior clinicians can use it when the hierarchy in front of them will not move. Merope Mills and Paul Laity treated that as evidence, not a side note.

It is hugely encouraging for us that a thousand clinically trained staff have already used Martha’s Rule. This is also clear evidence that issues such as hierarchy, poor communication and some doctors’ resistance to being challenged affect hospital care every day. Such factors were crucial to any explanation as to why Martha lost her life.

Merope Mills and Paul Laity, May 2026, NHS England

Dr Ian Higginson, president of the Royal College of Emergency Medicine, said patients should feel safe in emergency departments, “but we recognise that sometimes things can get missed by even the most skilled clinicians in A&E.” The second look in this model is usually another nurse from outreach, not a new consultant body standing up in casualty. That can be the right pair of eyes. It is still extra work for teams NHS England has said it will not enlarge.

Queensland Put Ryan’s Rule in Emergency Departments First

England is arriving late to a design other systems put in casualty from the start. Australian clinicians told Mills about Ryan’s Rule in Queensland, named after Ryan Saunders, who died in 2007 from an undiagnosed streptococcal infection. His parents felt their worries were not acted on in time. The English rule also draws on Call 4 Concern, the family-activated outreach line pioneered at the Royal Berkshire NHS Trust by critical care nurse consultant Mandy Odell.

HOW THE FORERUNNERS WERE BUILT

1. 2007: Ryan Saunders dies in Queensland; his parents’ concerns are not acted on in time.
2. 2009 to 2010: Call 4 Concern is piloted at the Royal Berkshire, giving families a direct line to critical care outreach.
3. 2 December 2013: The first facility went live in December 2013 with Ryan’s Rule; the last Queensland Health site joined on 19 May 2015.
4. 2021: Martha Mills dies at King’s College Hospital after sepsis is not escalated to intensive care.
5. 2022: A coroner rules she would probably have survived with an earlier intensive care transfer.
6. May 2024: NHS England’s first 143 Martha’s Rule sites begin; call data are counted from September 2024.
7. September 2025 to March 2026: Seven trusts test the rule in A&E; 69 calls are logged.
8. 22 September 2026: NHS England starts the national A&E and waiting-room expansion, due to finish by March 2028.

Ryan’s Rule applies to patients in Queensland public hospitals, including the emergency department. Families work through three steps: talk to a nurse or doctor, then the nurse in charge, then phone 13 HEALTH and ask for a Ryan’s Rule review. Shaune Gifford and Kate Smith, who led the Queensland rollout, said staff were nervous that people would ring with trivia, then found that making the call takes nerve and that volumes stayed modest. In 2023 there were 2,355 activations across 177 facilities, about seven calls a day; about 60% turned on communication, nearly 50% of reviews left planned care unchanged, and 61% of callers who gave feedback agreed their concerns were addressed.

Queensland put emergency departments inside the same system as wards and spent 17 months getting every facility live. England built the ward programme first, tested casualty on 69 calls, and has given itself until March 2028 to finish A&E, maternity and neonatal units. The wait is not a small scheduling detail. It is the time in which a family in a waiting room still has no advertised second look unless their own trust has already jumped the queue.

Most Deterioration Calls Never Trip the Score

The inpatient data show why a family view can catch what a chart misses, which is the argument for taking the tool into A&E. They also show who is most likely to know the number exists.

WHAT THE WARD NUMBERS SHOW

• Silent scores: Between June 2025 and July 2026, 82% of Martha’s Rule calls about acute deterioration would not have triggered escalation via the early warning score.
• Who calls: 72% of the 19,177 calls to July 2026 came from families and carers, not from staff.
• Who is seen: Among deterioration calls, 26.1% concerned patients in the most deprived groups and 14.5% the least deprived.
• Who has heard of it: An NIHR-funded survey of 2,047 people in September 2025 found 32% were aware of Martha’s Rule, 83% of them via the news; people with higher education were 4 times as likely to know, and awareness was 40% higher in upper income groups.

The 82% figure is the strongest case for a family-activated line. A score that stays quiet is exactly the gap that killed Martha: people at the bedside could see a child getting worse while the formal trigger did not fire. The awareness figures cut the other way in a waiting room. The evaluation also flagged barriers for people who are isolated, young people without a guardian, older adults, people with cognitive impairment, poor literacy, language barriers, and people from ethnic minority groups.

Those are not abstract groups in casualty. They are often the people sitting longest, with the least confidence to interrupt a busy nurse, and the least chance of having read a ward poster. A phone line that 32% of the public have heard of, mostly from the news, will not be evenly used at 3am in a queue. Actor Jason Watkins, whose daughter Maude died of sepsis in 2011 aged two and a half, backed the A&E move and told parents, “If you’re at all worried when you go into A&E, ask for a second opinion.” The advice only helps the parent who already knows there is a second opinion to ask for.

How Families Can Use the Rule Before 2028

The expansion has started. It is not in every department yet. Until the phased work finishes in March 2028, NHS England says patients and families should check a local trust website or ask staff whether Martha’s Rule is running in that hospital. Inpatient services are further on, at 221 sites, with that piece due to be completed in 2026/27. Maternity and neonatal units are on the same March 2028 clock, after the government in June 2026 ordered that extension following the Ockenden maternity findings.

Where the line is live, the sequence is simple. Raise the worry with the team looking after the patient. If that goes nowhere, call the advertised Martha’s Rule number. In A&E the review may be a senior nurse or an outreach clinician. Staff can make the same call if they are stuck. Watkins said the rule also gives doctors and nurses a pause, a chance to ask whether they have assessed a child as fully as they can.

The number is not a new A&E. It is a second pair of eyes, usually from a team that already has a pager full of ward work, in a department that has just taken 241,061 extra attendances in a single summer. Families who want it will have to ask, hospital by hospital, until March 2028, and they will have to get a signal in the waiting room when they do.

Disclaimer: This article is news reporting on an NHS England patient-safety policy. It is for information only and is not medical advice, a diagnosis, or an instruction on how to treat any condition. It does not tell readers when to seek emergency care or how to use a hospital phone line in a specific case. Anyone who is worried about a patient’s condition should speak to the clinicians looking after them, call the local Martha’s Rule number if it is available, or use emergency services, and should take clinical advice from a qualified doctor or nurse. Figures, site lists and rollout dates reflect NHS England and related public sources as published around 22 September 2026 and may change as the phased programme continues.