Client Story
Altera’s Sunrise EPR platform supports acceleration and scalability of Martha’s Rule rollout at Bolton NHS Foundation Trust
Bolton NHS Foundation Trust has used the Altera Digital Health’s Sunrise™ EPR platform to transform their delivery of Martha’s Rule from a standalone patient safety initiative into an integrated, scalable part of everyday clinical practice. Developed and refined through extensive testing, Bolton’s model combines 24/7 escalation routes for patients, families, carers and staff with a Patient Wellness Questionnaire (PWQ) that asks patients how they feel and whether they feel worse than previously.
Integrating the questionnaire into the Sunrise EPR platform has enabled Bolton to embed the process into existing clinical workflows, connect patient concerns directly to its recognition and response process, and move rapidly from ward-level testing to implementation across all inpatient areas. The approach is helping the trust identify deterioration earlier, strengthen the voice of patients and staff, support clinical judgement and intuition, and create a more consistent, measurable and sustainable approach to patient safety.
Integrating Martha’s Rule into clinical practice
Identifying patient deterioration earlier
Giving staff, patients, relatives and carers a stronger voice in care delivery
Accelerating scalability
Challenge
In 2022, Bolton NHS Foundation Trust joined the NHS England Worry Concern Collaborative and started supporting the early work to respond to Martha’s Rule. Martha’s Rule is a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon. It has been developed in response to the death of Martha Mills, a 13-year-old girl who died from sepsis in 2021 after being admitted to hospital with injuries sustained in a bicycle accident. Subsequent investigations found that concerns raised by her family about her deteriorating condition were not acted on, leading to the development of Martha’s Rule. While this incident did not occur at Bolton, it has served as a catalyst for a national initiative across all NHS organisations to review how patient and family concerns are recognised, escalated and responded to.
The trust was one of seven that came together as a practice community to develop an evidenced model prior to it being scaled nationally by 2026/27.
The model addresses several challenges:
- A situation in which someone could recognise that a patient was deteriorating but their concern wasn’t being heard or acted on through the usual escalation route.
- Supporting clinical teams to understand the pace and nuance of a deteriorating patient.
- The limitations of relying on formal scoring alone for deteriorating patients and recognising that professional judgement and intuition can also play a role in monitoring deterioration.
- Cultures where staff are reluctant to challenge clinical judgement.
- Integrating escalation into the normal care workflow rather than it operating as a standalone process.
- Overcoming additional patient safety risks generated by busy environments, such as Emergency Care, where there can be long waits and the potential for corridor care.
Solution
The model developed at Bolton comprises three components. A 24/7 phone line that patients, families and carers can use to escalate care when they don’t feel heard and a similar phone line for staff. Calls to both phone lines are triaged by a clinical site manager who routes it through to the appropriate escalation pathway.
The remaining component is the Patient Wellness Questionnaire (PWQ) that was tested and refined through PDSA (Plan Do Study Act) cycles, including how and when it should be asked. The questionnaire was initially conducted using a paper-based process before being integrated onto Bolton’s Sunrise EPR system, provided by Altera Digital Health. Once integrated, the EPR enabled the questionnaire to be incorporated into clinical workflows across all inpatient areas. If a patient reports deterioration, the system directs the health professional through the recognition and response process rather than creating an entirely separate clinical pathway.
Impact
Identifying patient deterioration earlier Martha’s Rule is supporting an additional way of identifying when a patient is deteriorating. Using the EPR to prompt clinicians to ask a patient how they feel every day compared to how they felt the last time they were asked is enabling deterioration to be identified faster and potentially saving lives.
The phone line is acting as an additional safety net for patients and staff, including staff outside of the traditional clinical escalation structure, such as porters and ward clerks, who may notice a change in a patient’s health.
Giving staff, patients, relatives and carers a stronger voice in care
The process is giving patients, relatives, carers and staff an additional route to raise concerns if they feel it hasn’t been heard which is contributing to fewer complaints and improved scores from the Friends and Family Test.
The trust worked in partnership with the Bolton Deaf Society to co-design safe and accessible access to Martha’s Rule for members of the deaf community to reduce communication barriers and strengthen patient empowerment.
Introducing the rule has helped to validate a nurses’ clinical judgement and intuition. Escalation isn’t just being flagged by observations and National Early Warning Scores (NEWS), instead it is including a nurses’ intuition in the overall escalation picture. It has helped Bolton to move towards a culture where a nurse is empowered to flag that a patient’s NEWS score is not raised but they are scoring red on worry and concern factors. Nurses have also reported feeling more connected and in tune with their patients because they are completing the questionnaire daily.
Integrating Martha’s Rule into the clinical workflow to drive consistently safe care
The flexibility and configurability of the trust’s Altera’s Sunrise EPR platform has enabled Bolton to integrate the Martha’s Rule process directly into established clinical practice. As well as recording patient questionnaire responses, it automatically links concerning responses directly into the existing clinical recognition and response workflow.
Rapid scalability
Before digitising Martha’s Rule, staff relied on a hardback book to complete the PWQ which limited testing and broader implementation. Embedding Martha’s Rule into the trust’s EPR has supported the process to be rolled out rapidly across all inpatient wards, scaling patient safety at pace. Martha’s Rule was created to provide safety interventions and the EPR is providing the foundation that makes it scalable, integrated into clinical practice, measurable and sustainable.
Next steps
Bolton intends to configure its EPR system so that the approach already established in inpatient areas can be extended into the Emergency Department, helping to ensure a consistent approach to Martha’s Rule across the organisation. The trust is also committed to continuously learning from helpline calls and patient feedback to refine and strengthen the service over time. This ongoing work builds on Bolton’s broader commitment to addressing health inequalities, including initiatives to ensure equitable access to Martha’s Rule provision for the deaf community, an achievement that was recognised with the Patient Involvement in Safety Award at the HSJ Patient Safety Awards 2026.