On World Patient Safety Day, Shakti Dookeran, Innovation Lead for the North West London Patient Safety Collaborative, reflects on how the nationwide implementation of Martha’s Rule is reshaping patient safety. And why embedding safety by design is critical to building trust, reducing harm, and improving outcomes.
The tragic story behind Martha’s Rule is a stark reminder of what happens when systems fail to listen, respond, and protect. And, it’s also been a powerful catalyst for change -showing how innovation, co-design, and service user input can transform patient safety from aspiration into lived reality.
In North West London (NWL) the Patient Safety Collaborative (hosted by ICHP) has been proud to support the launch of Martha’s Rule to an initial eight pilot sites. Working with all four acute trusts in our region, our team used quality improvement methods and collaborative learning to help frontline teams embed these new escalation pathways in ways that are practical, sustainable, and meaningful.
Martha’s Rule: A case study in systemic change
Martha Mills was a 13-year-old girl who died from sepsis in hospital after her parents’ concerns were not acted upon. Her death exposed deep flaws in escalation pathways (a critical component of patient safety) and communication between families and clinical teams. In response, Martha’s Rule was introduced (November 2024) across NHS hospitals to ensure patients, families, and staff have clear, accessible routes to escalate concerns when a patient’s condition deteriorates.
And it’s more than a policy. It’s three pillars – structured daily patient check-ins, staff escalation pathways, and patient, family, and carer escalation routes – are system redesigns to make the safe choice the easy choice.
These are not just policy changes or tick-box activities, these are tactics that embed safety into everyday practice and treat safety as a core design principle, not an add-on.
Embedding safety by design
The NWL PSC supports the system to reduce harm, improve outcomes, and foster a culture of continuous improvement. Our varied programme focuses on:
- Developing patient safety culture and leadership
- Building capability for quality improvement and measurement for improvement
- Coaching teams through quality improvement projects
- Bringing people—staff and patients—together to find sustainable solutions to patient safety concerns
By offering tailored support and fostering a culture of learning, collaboration, and continuous improvement, our aim is for patient safety to become a shared responsibility and a lived reality across care settings.
Culture Shift: From reactive to preventative
True safety leadership means anticipating risk and building workflows, cultures, and technologies that protect by default. This means:
- Investing in foresight: Prioritising technologies that predict and prevent.
- Empowering frontline staff: Giving clinicians tools that enhance their ability to spot and stop risks early.
- Embedding safety into design: Making safety a foundational principle in every innovation initiative.
Innovation as a moral imperative
One lesson stands out from our work on Martha’s Rule: embedding safety requires designing with, not for. Families, frontline teams, and service users must all be co-authors of change if we want solutions that last.
Patient safety is not a compliance exercise. It is a moral obligation. Innovation, coupled with foresight and compassion, transforms healthcare from a system that reacts into one that protects, prepares, and prevents.
As we look to the future, let’s champion innovation not just for what it makes faster or more affordable, but for what it makes safer.
More on Martha’s Rule
Want to find out more about Martha’s Rule? Get in touch with our Patient Safety Team, or read more about the roll-out of this initiative in NWL.
More on the NWL Patient Safety Collaborative
Find out more about the Patient Safety Collaborative‘s system-wide approach to patient safety is delivering impact in our region:
