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In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Helen and Peter speak to Bethany Carter, currently Head of Quality and Clinical Governance at Combat Stress. Bethany discusses her career from military nursing and infection control to becoming a Freedom to Speak Up Guardian and later a senior leader at the National Guardian’s Office. She reflects on how organisational culture determines whether staff feel safe to raise concerns, drawing on both positive and negative personal experiences of speaking up. The interview explores the importance of supporting Guardians, strengthening managers’ ability to listen and respond, protecting staff from detriment, and maintaining independent national oversight as the National Guardian’s Office closes. Bethany's central advice is that anyone with a concern should not be deterred by terminology or process: they should find someone they trust, seek support and speak up so organisations can learn and improve. Subscribe to our YouTube podcast to keep up to date with the latest episodes. Transcript of the interview Read a blog from Peter and Helen about the interview series

This year’s World Patient Safety Day on 17 September is focused on the theme ”Safe care for noncommunicable diseases”. To support you with your World Patient Safety Day activities, Patient Safety Learning has created a poster for you to print out and display within your organisation. There are two versions attached to download: A4 and A3, with blank spaces in the top-right for organisation's to drop their logo in before printing. The third attachment features guidance on where an organisation should feature their logo and preferred size in relation within the available space. patient-safety-day-poster-A3.pdf patient-safety-day-poster-A4.pdf patient-safety-day-poster-logo-placement-guidance.pdf We'd love to see photos and hear how you're using the poster and your World Patient Safety Day activities. Comment below. You will need to be a hub member and signed in—sign up here.

This is a poem written and read by Elaine Freeman, Patient Safety Partner (PSP) at Lincolnshire Community and Hospitals NHS Group. Elaine and her PSP colleagues shared their poems with the Group Chief Governance Officer, her deputy, and the new Chair of the Group, inviting reflection on the importance of patient-centred care. The PSPs chose poetry as a powerful and personal way to express their experiences, insights, hopes, and concerns, and to highlight the human story behind the numbers. Two other poems they shared are included at the end.  The video has been created by Patient Safety Learning.  The human Behind the Digit I am the person behind the number, The face behind the case, The story in the spreadsheet, A name you can’t erase. I’m more than just a metric, A target or a trend, I’m a mother, father, sister, A neighbour and a friend. When you look at columns, And data on the screen, Remember there’s a heartbeat, And a life that’s lived between. So, as you make your choices, And the digits start to climb, Don’t lose the human spirit, In the pressure of the time. Other poems by the Patient Safety Partners Can you hear me? By Ruth Krampf Can you hear me? You told us that my partner needed to come in for some tests. You told us that my partner’s future was grim. My partner was frightened. Can You Hear Me? We came to you. I told you my concerns about my partner. I told you about my partner’s condition. Can You HEAR Me? You put my partner on Nil by Mouth. Nobody told me. Doctor take your eyes away from your tablet and look at us. Listen to us! CAN You HEAR Me? My partner is not a metric, they are confused. My partner is not a tick box, they are anxious. My partner wants to come home. CAN YOU HEAR Me? My partner is not just another statistic to put a tick against. My partner is a spouse, parent, sibling and friend. My partner is loved. CAN YOU HEAR ME? The Human Behind the Digit (2) By Elaine Freeman The screen is filled with rows of green, A grid of targets, met and signed. But in the spaces in between, What of the souls we’ve left behind? A metric is a frozen thing, A snapshot of a process done, But safety is the life we bring To every daughter, father, son. A 'tick' is not a healing hand; A 'box' is not a life restored. We need a Board to understand The truths that live beyond the board. For outcomes are not found in ink, Or graphs that track a steady line, But in the time we stop to think: “Is this a person, or a sign?” So let the data find its place, But let the patient lead the way. Put back the name, the story, the face, Into the words we choose to say. True success is not a score, Or how we’ve played the system’s part; It’s when we open up the door And lead with data—and with heart.

Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

The Healthcare Governance Academy, PSIRF training trusted by more than 4,000 healthcare professionals. Delivered by a patient safety consultant that developed PSIRF tools. This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries WHO SHOULD ATTEND Executives, commissioning, & service managers supporting service lead investigator roles. The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting. Register hub members receive a 20% discount. Email [email protected] for discount code.

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members receive a 20% discount. Email [email protected] for discount code.

Any staff with responsibility for implementing the duty of candour and/or PSIRF and those responsible for quality; safety; clinical governance; safety investigations; complaints; CQC compliance; or patient experience/ involvement would benefit from attending this one-day training. The course will provide participants with an in-depth knowledge and understanding of how to not only comply with the duty of candour and the Patient Safety Incident Response Framework (PSIRF), but to do so in an emotionally intelligent way, with empathy and compassion for all involved. Practical guidance on complying with the regulations and guidance The “grey areas” and what people most often get wrong Using emotional intelligence to understand the difficult emotions experienced by patients/those closest to them and staff following patient safety incidents What empathy and compassion mean in practice Handling difficult and emotive conversations well Making a meaningful apology How Duty of Candour and PSIRF work alongside other policies and procedures including complaints; litigation; Martha’s Rule and the soon to be introduced “Hillsborough Law” How the new “Harmed Patient Pathway” can help you get it right 7 How to ensure communication moves beyond compliance and frameworks but remains emotionally intelligent and personal Register hub members receive 20% discount. Email [email protected] for discount code.