Written by Graham Mason, Associate Medical Director for Quality and Safety, Royal Manchester Children’s Hospital (RMCH), Manchester University NHS Foundation Trust (MCS)

As part of our commitment to improving patient safety and responsiveness, we’ve spent the past year piloting the integration of Martha’s Rule into everyday clinical practice. This blog shares key lessons from our journey—highlighting how we’ve tailored education, used data to drive insight, and listened to families to shape a more inclusive and effective approach.

Over the past year, our focus has been on embedding the components of Martha’s Rule (MR) into everyday clinical practice—ensuring that staff across all levels understand their role in the process and feel equipped to respond effectively to concerns raised by patients and families.

One of our earliest challenges was designing education that resonated with different staff roles. We recognised that ward nurses, medics, and other clinical teams needed training that reflected their specific responsibilities within the MR pathway. Initially, we concentrated on face-to-face sessions supported by PowerPoint presentations. These laid the groundwork for understanding MR, but we knew we needed something more scalable. That’s why we developed an e-learning package, which is now live on the E-learning hub and is included in staff Mandatory Training. The e-learning package is structured to provide appropriate awareness within individual staff groups, ensuring consistent understanding of deterioration, across the board.

From a data perspective, we explored how to assess the safety of our current system and identify what information we needed to monitor effectiveness. We examined numerical indicators such as:

•     Deterioration rates
•     Cardiac arrest calls
•     Admissions to Paediatric Critical Care

In addition, we collected qualitative data around:

•     Complaints and incidents—especially those involving parental concerns

We triangulated these data sources to build a clearer picture of where improvements were needed. While much of this analysis has been internal, we’ve begun integrating elements into the HIVE system,  to create dashboard-style visibility. We’ve also developed a dedicated database to track MR calls, allowing us to identify themes and trends by team, location, age, ethnicity—and potentially deprivation.

Although patient groups weren’t directly involved in shaping the e-learning package, we did engage with families during the early stages of the MR pilot. Their feedback was invaluable. Many expressed frustrations about unanswered queries and feeling left in limbo and feeling disempowered by a lack of cohesive response. These insights helped us reinforce key messages in the training, particularly around how concerns are acknowledged and escalated.

Looking back, we recognise that capturing family feedback earlier would have strengthened the process. We’re now addressing ongoing challenges, especially for families whose first language isn’t English. While many preferred phone communication, we’ve taken steps to improve accessibility.

We’ve created a multilingual space on the MR site, allowing users to select their preferred language. To bridge the gap between ward posters and digital resources, we have added QR codes that link directly to the site. This will include contact details for the MR team and background information about the initiative. It’s a tangible outcome of the pilot and a testament to how much we’ve learned along the way.

Encouragingly, families have reported that their concerns are being responded to once MR calls are made. We’re also mindful not to interpret low call volumes as a sign that everything is fine. That’s why we continue to monitor all sources of information, ensuring we’re not missing signs of deterioration.

From pilot wards, we haven’t seen incidents or complaints that suggest missed cases, nor admissions to critical care that raise red flags. But vigilance remains key.

The e-learning package will be rolled out beyond pilot wards ready for a hospital wide rollout in mid-October 2025, ensuring widespread access and training before full expansion. MR principles are now embedded in induction for new nursing staff and resident doctors, reinforcing our commitment to making MR a core part of our culture.