Government have announced mothers and newborns across England will be ‘better protected’ as Martha’s Rule is rolled out to all maternity and neonatal settings.
Under the rule, parents can ask for an urgent review by a separate medical team if they feel concerned about a mother or baby are being ignored.
Rollout follows Donna Ockenden’s review into Nottingham University Hospitals NHS Trust (NUH) – the largest of its kind in NHS history. Her team examined the maternity care experienced by 2,500 families and found ‘women ignored or complaints dismissed, missed opportunities to identify deteriorating patients and a culture of silencing both junior staff and parents’.
The review also found 444 women and 76 babies suffered ‘potentially avoidable’ harm as a result of substandard maternity care over a 13-year period at NUH.
Ockenden said: ‘To every family who came forward, I want to say this: we have listened. It is my sincere hope that through this review you now feel as though your voices have been heard and what happened to you and your families has been recognised and will be acted upon.’
Martha’s Rule is already in place for adult patients in all acute hospitals in England and has been piloted in 15 maternity and neonatal settings. Further sites will go live this year.
NHS data shows more than 2,100 calls to Martha’s Rule have already led to changes in treatment. In over 600 cases it triggered life-saving care, such as moving patients to intensive care.
The rule is named after Martha Mills, who tragically lost her life at just 13-years-old in 2021. She had sepsis after being admitted to hospital with a pancreatic injury from a bike fall.
‘Martha’s family’s concerns about her deteriorating condition were not responded to,’ the government said. A coroner ruled in 2022 that Martha would probably have survived if she had been moved into intensive care sooner.
Health Secretary James Murray said: ‘Donna Ockenden’s review lays bare a culture where too many voices went unheard, too many opportunities to prevent harm were missed and too many lives were lost. That’s why we have to take action, and quickly.’
‘No family should ever have to battle the system that is meant to care and protect them, that is why Martha’s Rule is so fundamental,’ he continued. ‘It provides a way for a concerned mum, or family member to raise the alarm before it is too late.’
Ministers said staff who are responsible for failures will have to give evidence to investigations into poor maternity care. Those who refuse or hide information could face up to two years in prison.
The changes aim to end a ‘culture of silence’. In Nottingham, more than 800 staff gave evidence and many said they were silenced by their superiors when they raised safety concerns.
Mortuary checks will also be tightened. It follows findings of ‘the lack of respect given to deceased babies, and the complete disregard to their dignity’. The Human Tissue Authority will make all mortuaries review records from 2015-2026 to ensure nothing was missed.
Michelle Welsh MP, the government’s first maternity adviser, said: ‘Donna Ockenden’s review is a stark reminder of the devastating consequences when women, families and frontline staff are not listened to.’
She added: ‘We owe it to every mother, baby and family affected by these failures to ensure that lessons are learned and that meaningful improvements are delivered across the NHS.’
NUH has launched a new helpline for families who have used its maternity and neonatal services, of which details can be found here.
The government is expected to give a full response to Ockenden’s national recommendations in September 2026.
Image: Shutterstock
In related news:
Leave a Reply