richard vA

Given my concerns about how Patients and Families are utilised, or not in learning investigations,  by even the leading exemplar service i am interested to read this and will feedback my thoughts,  as I was one of the patient contributors to the Discovery phase and did comment on this whole project some time ago expressing my views 

well put-there is a difference between a complaint and a report of harm in my opinion. , but each deserve full respect, attention and centering pf patients views, for similar reasons. hsib is looking at harm reduction and  looking at systemic issues-which patients are well able to engage with if given an opportunity-their efforts should be respected fully

I do hope other comments will be added. The incoming Board requires constructive food for thought as it launches the next stage with theoretically&  legally more powers and independence but in a just as challenging context.  Learning from tragic deaths of mental health patients requires huge sensitivity,   sophistication and patient and family centredness 

And may involve listening but no empowered action as I mentioned in recent tweet replies in calls for more mere 'listening :...... ''But what action do you demand after listening? Listening without robust action is tokenistic,  falsely raising expectations and is further disempowering and traumatising to patients if not backed up  by patient moderated/enhanced outcomes. Ask @BeresfordPeter @DavidGilbert43. Also reply in another related context. Progress in this area is SO slow https://x.com/twitsquince/status/1711552623784988872?t=_KknwvgmS8GR5LwHu_UnNw&s=08

But what action do you demand after listening? Listening without robust action is tokenistic,  falsely raising expectations and is further disempowering and traumatising to patients if not backed up  by patient moderated/enhanced outcomes. Ask @BeresfordPeter @DavidGilbert43. Also reply in another related context. Progress in this area is SO slow https://x.com/twitsquince/status/1711552623784988872?t=_KknwvgmS8GR5LwHu_UnNw&s=08

Excellent.  Please don't forget work & feedback to a @theHSSIB report,  additional family insights, role of family feedback and coordination between palliative and oncology services all linked in this article 

Can a more accessible link be shared?. I am not on linked in

Great image. Power differential, interests,  positioning of placed expertise, status,  uni directional process.  Captured here. No one listens  or is interested  ( ok ..we had one response)

NRLS  now is LFPSE. Hopefully someone from there can respond.  They are currently asking if and how Patients and Families can report events in another blog on this site. Link below.  Astounding there is no plan yet and no massive patient consultation process

Where are patients and whistleblowrs? Elephants in the room

What about dealing with managers who protect bad apples and victimise whistleblowrs? Key system reforms needed of this even worse problem IMHO.  System coverup is worst issue .As @alexander_minh has argued for years based on masses of data& correspondence2 systemic radical reforms are essential starting point: 1.whistleblowrs protection reform 2.managerial accountability. I add: like @DavidGilbert43 3.empowered patient leadership throughout org. Agree?

This first step is so important..who controls it ia a key concern. 

Some excellent patient leadership campaigners have questioned if there is any real empowered embedded patient voice in the whole process. I share the concern. The blog above highlighs need for more than stories. Structural engagement and change needed. It will come about if patients are empowered in the process.

I asked at my one hour session that harmed patient experts by experience are involved  in drafting of this key report. Nothing about us without us. I am still seeking assurance 

No one currently investigates patient reports of harm from the patient perspective,  with a patient eye view & patient interests at heart.  They would require  both TRUE INDEPENDENCE ( of the reputation protecting NHS Trust involved and also be a fearless challenger, if needed  of the existing NHS  system and clinical base)  AND TRUE WIDE RANGING EXPERTISE  ( clinical,  human factors, safety & patient need focus), all woth with PATIENT OVERSIGHT  ( empowered. Informed. Suitably Rewarded. Co produced in a nutshell). Who can do that? Who will dare do that.  It is needed,  urgently . Will NHSE patient Safety dare? If you have thoughts: share here. Contact NHS staff above

No one currently investigates patient reports of harm from the patient perspective,  with a patient eye view & patient interests at heart.  They would require  both TRUE INDEPENDENCE ( of the reputation protecting NHS Trust involved and also be a fearless challenger, if needed  of the existing NHS  system and clinical base)  AND TRUE WIDE RANGING EXPERTISE  ( clinical,  human factors, safety & patient need focus), all woth with PATIENT OVERSIGHT  ( empowered. Informed. Suitably Rewarded. Co produced in a nutshell). Who can do that? Who will dare do that.  It is needed,  urgently . Will NHSE patient Safety dare? If you have thoughts: share here. Contact NHS staff above

Something is happening but it is under radar of too many patients.  Where do patient report harm events.  No where...still...yet. how can they?

I have been made aware of a consultation happening as part of a Discovery Phase for the development of The Learn from Patient Safety Events (LFPSE) service. See below for the information I received:

Consultation by NHS England. "Discovery Phase is taking place over around 8 weeks, with the involvement of a Patient Safety Partner recruited through our internal processes.

I’ve included an excerpt from the Task Profile we used for recruitment below, which explains more about the phase and its aims.

1.          The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare. This utilises new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. The service introduces a range of innovations to support the NHS to improve learning from the over 2.5 million patient safety events recorded each year, to help make care safer (see ‘How LFPSE will improve patient safety learning’). View this short animation: Introducing the Learn from Patient Safety Events service - YouTube.

2.         Patients Safety Partner involvement is important for understanding how best to ensure patients, carers and families can contribute to national patient safety learning and improvement. The LFPSE project team are undertaking a Discovery Phase to understand how Patients and Families can best share their safety experiences within the NHS to help support national learning and improvement. A ‘discovery phase’ is a process that helps to “define the problem” and decide what (if any) work then needs to take place (e.g. designing and building software/applications).

3.         The work will involve identifying target audiences (who else do we need to involve in the research?), what needs they are trying to meet (their aims after experiencing a patient safety event), what existing feedback channels or processes there are in place (where do people already go when wanting to share such information and experiences?), and any concerns/issues with current options (what stops people sharing their experiences? What makes it difficult to do? What gets in the way of this being used for learning?). At the end of the discovery phase, we will produce a report that summarises our findings, and makes recommendations for what should happen next. “

We are recruiting patients and families via a number of channels – some directly, like yourself, where they have expressed an interest previously, and some via NHS England’s engagement teams, as well as via CQC. We have reached out to a number of advocacy groups (AvMA, Patients Association, Harmed Patients Alliance, and Care Opinion) to try to get a wide range of views represented, both of patients with experience of harm, and those without. This is important to ensure we design a user-friendly service for “novice” patients, as well as those who understand the landscape of patient safety better.

The questions asked will cover things like whether the individual has any personal/family experience of harm; if not, do they know what a patient safety incident is, how they would describe the concept in their own words, where they would go if they had an experience that might involve a patient safety issue, what they would want out of that process, etc.

The intention is very much to get a sense of the current state of play, level of knowledge and awareness of issues, terminology, and options open to patients, and to then use that to explore what kind of service will work best to ensure we can gather the learning from patients for use at a national level, whilst also giving patients what they need in terms of feedback/closure etc (which will likely need to happen at the provider level, rather than nationally).'

to ask to be involved contact lucie.mussett@nhs.net  or natasha.hughes@nhs.net

The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare patient reporting of harm. NHS have announced a new Discovery Phase for the development of the LFPSE, which includes engaging patients. This is vital and unknown about, and needs urgent attention. I have already raised my concerns. 

See below for the information I have received and how to get involved:

"Discovery Phase is taking place over around 8 weeks, with the involvement of a Patient Safety Partner recruited through our internal processes – I’ve included an except from the Task Profile we used for recruitment below, which explains more about the phase and its aims.


1.          The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare. This utilises new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. The service introduces a range of innovations to support the NHS to improve learning from the over 2.5 million patient safety events recorded each year, to help make care safer (see ‘How LFPSE will improve patient safety learning’). View this short animation: Introducing the Learn from Patient Safety Events service - YouTube.


2.         Patients Safety Partner involvement is important for understanding how best to ensure patients, carers and families can contribute to national patient safety learning and improvement. The LFPSE project team are undertaking a Discovery Phase to understand how Patients and Families can best share their safety experiences within the NHS to help support national learning and improvement. A ‘discovery phase’ is a process that helps to “define the problem” and decide what (if any) work then needs to take place (e.g. designing and building software/applications).


3.         The work will involve identifying target audiences (who else do we need to involve in the research?), what needs they are trying to meet (their aims after experiencing a patient safety event), what existing feedback channels or processes there are in place (where do people already go when wanting to share such information and experiences?), and any concerns/issues with current options (what stops people sharing their experiences? What makes it difficult to do? What gets in the way of this being used for learning?). At the end of the discovery phase, we will produce a report that summarises our findings, and makes recommendations for what should happen next. “

We are recruiting patients and families via a number of channels – some directly, like yourself, where they have expressed an interest previously, and some via NHS England’s engagement teams, as well as via CQC. We have reached out to a number of advocacy groups (AvMA, Patients Association, Harmed Patients Alliance, and Care Opinion) to try to get a wide range of views represented, both of patients with experience of harm, and those without. This is important to ensure we design a user-friendly service for “novice” patients, as well as those who understand the landscape of patient safety better.

The questions asked will cover things like whether the individual has any personal/family experience of harm; if not, do they know what a patient safety incident is, how they would describe the concept in their own words, where they would go if they had an experience that might involve a patient safety issue, what they would want out of that process, etc.

The intention is very much to get a sense of the current state of play, level of knowledge and awareness of issues, terminology, and options open to patients, and to then use that to explore what kind of service will work best to ensure we can gather the learning from patients for use at a national level, whilst also giving patients what they need in terms of feedback/closure etc (which will likely need to happen at the provider level, rather than nationally).'

to ask to be involved contact lucie[.]mussett[@]nhs.net  or natasha[.]hughes[@]nhs.net

This touches on similar issues 

 and the review is currently forging ahead. Contribute. The patient voice is vital. Read next comment about what NHS is planning. I am concerned it is too little rushed through.  Serious empowred co production is needed.. what do others think?

The above is NHS patient safety response to this below.  I.am very concerned that the full vital patient voice will not be heard. This is a defining moment.  

So sorry to hear.  The big question.  Who can patients and their families report these harm events to? To get independent expert patient focussed action.  No one from my experience.  There is a national consultation process needing engaging with. This must be done . Read here and please also share widely. If not now when?

See below for the information I received:

I’ve included an excerpt from the Task Profile we used for recruitment below, which explains more about the phase and its aims.

 "Discovery Phase is taking place over around 8 weeks, with the involvement of a Patient Safety Partner recruited through our internal processes – I’ve included an except from the Task Profile we used for recruitment below, which explains more about the phase and its aims.

1.          The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare. This utilises new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. The service introduces a range of innovations to support the NHS to improve learning from the over 2.5 million patient safety events recorded each year, to help make care safer (see ‘How LFPSE will improve patient safety learning’). View this short animation: Introducing the Learn from Patient Safety Events service - YouTube.

2.         Patients Safety Partner involvement is important for understanding how best to ensure patients, carers and families can contribute to national patient safety learning and improvement. The LFPSE project team are undertaking a Discovery Phase to understand how Patients and Families can best share their safety experiences within the NHS to help support national learning and improvement. A ‘discovery phase’ is a process that helps to “define the problem” and decide what (if any) work then needs to take place (e.g. designing and building software/applications).

3.         The work will involve identifying target audiences (who else do we need to involve in the research?), what needs they are trying to meet (their aims after experiencing a patient safety event), what existing feedback channels or processes there are in place (where do people already go when wanting to share such information and experiences?), and any concerns/issues with current options (what stops people sharing their experiences? What makes it difficult to do? What gets in the way of this being used for learning?). At the end of the discovery phase, we will produce a report that summarises our findings, and makes recommendations for what should happen next. “

We are recruiting patients and families via a number of channels – some directly, like yourself, where they have expressed an interest previously, and some via NHS England’s engagement teams, as well as via CQC. We have reached out to a number of advocacy groups (AvMA, Patients Association, Harmed Patients Alliance, and Care Opinion) to try to get a wide range of views represented, both of patients with experience of harm, and those without. This is important to ensure we design a user-friendly service for “novice” patients, as well as those who understand the landscape of patient safety better.

The questions asked will cover things like whether the individual has any personal/family experience of harm; if not, do they know what a patient safety incident is, how they would describe the concept in their own words, where they would go if they had an experience that might involve a patient safety issue, what they would want out of that process, etc.

The intention is very much to get a sense of the current state of play, level of knowledge and awareness of issues, terminology, and options open to patients, and to then use that to explore what kind of service will work best to ensure we can gather the learning from patients for use at a national level, whilst also giving patients what they need in terms of feedback/closure etc (which will likely need to happen at the provider level, rather than nationally).'

Great work Tim . The link to the press release does not appear to work?

No luck with RCEM. Other routes being pursued for treating pain management seriously . Will report back later.

Please respond to this summary of a harmful system for whistleblowrs,  so patients https://minhalexander.com/2017/04/08/engineered-failure-to-investigate-nhs-whistleblowers-concerns/

There are many very differing views on the crisis and scandal around NHS  whistleblowrs and a much less optimistic account by a remarkable fearless campaigner is linked below deserving coverage on this site. There are real dangers of powerful interests causing additional mayhem, and I am not exaggerating one iota ! https://minhalexander.com/2023/05/09/the-whistleblowing-hunger-games-why-we-should-reject-the-whistleblowing-appg/