Improving the quality and safety of care: Managing deteriorating patients

Since we were first established over a decade ago, management of deteriorating patients has been one of our key areas of focus for improving patient safety.

We spearheaded use of the National Early Warning Score (NEWS2) across the entire region at all interfaces of care, as well as helping to standardise the delivery of basic care and improve resilience in emergency departments during periods of crowding through development of the ED Safety Checklist.

We feel privileged to be able to build on this work in the last year by supporting the local implementation of Martha’s Rule.

We have been able to align Martha’s Rule (as well as other programmes) with the move to the new Patient Safety Incident Response Framework (PSIRF), setting out the revised NHS approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.

This is helping to reduce silo working and reinforcing the golden thread of safety culture throughout our leadership of the West 0f England Patient Safety Collaborative.

A massive thank you for all your support - your input has been invaluable. We were talking about your insight into PSIRF and how that has been great for the group.

Bath and North East Somerset, Swindon and Wiltshire Medicines Safety and Quality Group

Supporting introduction of Martha’s Rule

Challenge

Martha Mills died in 2021 after developing sepsis in hospital, where she had been admitted with a pancreatic injury after falling off her bike. She was 13 years old.

Martha’s family’s concerns about her deteriorating condition were not responded to, 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 relating to how we manage the deterioration of patients, NHS England committed to implement ‘Martha’s Rule’ – a patient safety initiative to ensure the vitally important concerns of the patient and those who know the patient best are listened to and acted upon.

Martha’s Rule allows patients, families, carers and staff who are concerned about a person’s condition to access a rapid review.

Approach

As part of our support for the national NHS Patient Safety Improvement Programme, in 2024-25 we supported the pilot of Martha’s Rule across the three integrated care systems in the West of England, working with six hospital sites.

We have provided tailored, site-specific support, recognising that each trust and ward has unique local needs and may have different starting points. Some have been involved in similar related pilots, such as ‘Worries and Concerns’, while others are beginning completely from scratch.

This support includes monthly one-to-one sessions, featuring advice on quality improvement (QI) approaches and coaching to troubleshoot specific challenges. We also host monthly Share and Learn sessions to provide a valuable safe space for collaboration and learning across the trusts.

Result

Through our collaborative learning approach, we have identified several shared issues that we have been able to successfully learn from and make progress in tackling together. These have included communication, data collection, and fostering culture change.

In 2025-26 we will build on these insights to continue to support pilot trust sites across the West of England to test and implement Martha’s Rule.

The commitment of the sites and the potential for Martha’s Rule to truly empower patients, families and staff to improve safety is clear. It represents a fundamental shift towards a more listening and supportive healthcare system.

Siobhan Lanigan Registered Nurse and Senior Project Manager, Health Innovation West of England

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