Siobhan Lanigan is a Critical Care Nurse at the Bristol Royal Infirmary on secondment to Health Innovation West of England to support the local rollout of Martha’s Rule. In this blog, Siobhan reflects on a recent webinar sharing learning from Australia on developing processes for patients, carers or families to directly escalate care.
This month, I felt genuinely privileged to organise a webinar that I had been looking forward to for quite some time, ‘Learning from Ryan’s Rule: Insights for Martha’s Rule in England’.
The session was chaired by Alison Tavare, a GP by profession and one of the clinical leads I have the pleasure of working alongside as we support our sites in piloting and testing Martha’s Rule in the West of England. I always enjoy collaborating with Alison; her commitment to improving early recognition of deterioration and empowering patients is inspiring, and her thoughtful chairing really set the tone for an open and reflective discussion.
We were also extremely fortunate to welcome two Patient Safety and Quality staff members – Di O’Kane and Shaune Gifford – from Clinical Excellence Queensland, part of Queensland Health.
Shaune manages the Ryan’s Rule programme that supports Queensland Health Hospital and Health Services to meet the National Safety and Quality Health Service Standards required for accreditation (section 8.07 Escalating Care) – in which all health service organisations are required to have processes for patients, carers or families to directly escalate care.
Shaune has played a key role in the development and implementation of Ryan’s Rule since its inception and he gave an insightful and thought-provoking presentation on their learning to date. His passion for patient safety came through so clearly, and it is easy to see why Ryan’s Rule has been such a success in Queensland under his support and leadership.
As I listened to the conversation unfold, I found myself reflecting on just how powerful it can be when patients and families are given a clear, structured way to raise concerns about acute deterioration. The experiences shared from Queensland Health, Australia really resonated with me, particularly the way Ryan’s Rule has helped bridge communication between patients, their families and clinical teams at moments of great vulnerability. It reinforced for me why the rollout of Martha’s Rule here in England is so important, and how much we can learn from those who have walked this path before us.
By the end of the session, I felt both inspired and reassured: inspired by the dedication of those leading this work and reassured that we are building a system that truly listens and values the unique contribution patients and their families bring in recognising early signs of deterioration.
Ryan’s Rule and Martha’s Rule
Listening to Shaune share Queensland Health’s experience really brought to life what a mature, patient-centred escalation system can achieve.
Ryan’s Rule, established following the death of three-year-old Ryan Saunders, consists of a series of three steps that a patient, their family member or carer can take to raise their concerns when the patient in hospital is getting worse or not doing as well as expected. These steps facilitate a clinical review of the patient. The patient, family member or carer can continue to escalate through the series of steps if they are not satisfied with the outcome after each step. It is a 24-hour safety net designed to ensure that when a patient or their loved ones sense that something is not right, there is always a clear and responsive route to escalate those concerns.
What struck me most was how embedded and familiar Ryan’s Rule has become in Queensland Health’s hospitals. The process is simple and structured. Families are encouraged first to raise their concern with the nurse, midwife or doctor caring for them, then with the nurse or doctor in charge, and, if they still feel unheard, they can call a dedicated phone number to request an independent clinical review. It is a model that reflects years of trust-building between patients, families and clinicians.
As Shaune described, one of the most significant operational lessons is the need to understand and resolve patient concerns early. Many Ryan’s Rule reviews resulted in no change to the care plan, which highlights how many issues could potentially be addressed in those early conversations before formal escalation is needed. This really resonated with me, as it echoes what I often hear in conversations with our own site leads: families usually just want to understand what is happening and to feel reassured that someone is listening.
As we work to implement Martha’s Rule here in England, I could not help but draw parallels. Like Ryan’s Rule, it is rooted in the loss of a child, 13-year-old Martha Mills, and her parents’ determination to ensure that no other family experiences the same. Both initiatives are built on the same principle: that patients and their families are not passive recipients of care but partners with vital insight into a patient’s wellbeing.
Understanding the early signs of deterioration
Another powerful insight from Queensland Health is the recognition that a patient’s sense of concern does not always align with a clinician’s perception of deterioration. I have seen this myself, those moments when a family member quietly says, “Something doesn’t feel right,” even when the vital signs are within range.
To enhance the early recognition and response to deteriorating paediatric patients, based on a study undertaken at Monash Children’s Hospital, Melbourne, Victoria, Queensland Health has started embedding a simple question into their Children’s Early Warning Tool: “Are you worried your child is getting worse?” Research shows that when a parent answers yes, it can be a more accurate predictor of deterioration than any single abnormal vital sign. It acknowledges that parents are often the experts in the room when it comes to their child’s baseline.
This approach closely aligns with one of the components of Martha’s Rule: introducing a patient wellness questionnaire as a structured way to ask patients how they are feeling and whether their condition is improving or worsening. It fosters a culture of greater patient engagement, which can enhance the early detection of acute illness and strengthen communication between staff and patients.
Building trust, access and sustainability
Queensland Health’s experience also offers important lessons about governance, equity and sustainability. Every one of their 16 Hospital and Health Services has a dedicated Ryan’s Rule coordinator, ensuring consistent oversight and learning across the state. Hospitals were required to meet clear readiness criteria before going live, including local policy development and at least 80 per cent staff training. This structured, staggered approach, coupled with regular reviews of complex cases, has helped the system endure for more than a decade.
What I found particularly impressive was the role of the ‘13 HEALTH’ call centre, which acts as both a triage and screening mechanism. Calls are assessed quickly to ensure they meet the criteria for a Ryan’s Rule call and that steps one and two have already been attempted. If a call falls outside the escalation remit, for example if it is more of a complaint about a health service, the adviser can provide details of the consumer liaison officer at the hospital whom they can contact directly. It is a practical system that maintains the integrity of the escalation process while still offering support and signposting.
Shaune also highlighted the importance of building trust and ensuring equitable access. People rarely misuse the system, and where challenges exist, such as language barriers or cultural differences, Queensland Health has responded by producing educational materials in multiple languages and for First Nations communities. The proactive inclusion of the “are you worried” question further helps ensure that everyone, regardless of background, has permission to speak up.
Lessons for Martha’s Rule
Reflecting on Queensland Health’s decade of experience, I am struck by how many of the lessons are already resonating here in England.
We must focus on understanding concerns early and create space for those conversations to happen before they escalate.
We need to ask, listen and recognise early signs of deterioration and trust that families often sense deterioration before they show up in routine measurements.
Governance, transparency and sustained education are essential if this work is to take root and endure.
Above all, we must keep building trust – in patients, in staff and in the process itself.
Both Ryan’s Rule and Martha’s Rule share the same fundamental goal: listening to patients and families before it is too late. For me, that is what this work is about, creating a culture where every voice matters and where patient safety grows from empathy, trust and genuine partnership.
Find out more about Ryan’s Rule.
Read more about Martha’s Rule.
Posted on October 29, 2025 by Siobhan Lanigan, Senior Project Manager, Health Innovation West of England
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