Martha's Rule review request

If you're worried that someone is seriously unwell and you would like to request a review by the Critical Care Outreach Team, please complete this form.

Please make sure you also speak to the nurse in charge of the ward who can review the patient and directly contact the Outreach team if a quicker response is needed.

If you have not been contacted or reviewed within 4 hours, please follow up directly with the nurse in charge to ensure the referral has been received.

Learn more about Martha's Rule.

If your worry is not about someone who is unwell, please talk to the nurse in charge or the Patient Advice and Liaison Service (PALS). They are happy to help with any other worries or complaints.

Please tell us:

Your name*

Your contact phone number*

Confirm your contact phone number*

Full name of the patient*

Please select which hospital the patient is in*

What is the name or number of the ward the patient is currently staying on?*

Please provide a brief summary of your worries*

I consent to having my information stored for the purpose of this online form. I know you may need to contact me in relation to my form. I understand that if I don't consent I cannot submit online.