Patient_Safety_Learning

At Patient Safety Learning, we believe listening and learning from different perspectives, expertise and experiences is essential in understanding the complexities, challenges and potential solutions around patient safety issues. Reducing avoidable harm in health and social care cannot be done in isolation; collaboration is key.  In this blog, we reflect on some of this year’s activities and celebrate people who are working together for safer care and recognising the value of different perspectives.  Background In 2019 we launched a free online platform for anyone interested in patient safety - the hub – designed to help people share learning. Since then, the hub has had over 1.4 million visitors, and today it is a thriving, global community of people. By connecting patients, frontline staff, managers, families, researchers, medtech companies, regulators, policy makers, patient safety partners and many more, the hub offers a unique space for people to work together to improve patient safety. More recently, the hub has also provided an online space and support for several networks of people involved in patient safety. We are helping to facilitate deep and psychologically safe conversations among peers about some of the most challenging and inspiring aspects of patient safety. Discussions are varied, with members exploring topics like how to engage with patients and families following an incident, building a just culture, and how best to collaborate for safety. Celebrating collaborative working Experts in a room Electronic patient records (EPRs) are a way of managing clinical information with the intention of making it more easily accessible to both healthcare professionals and patients. EPR systems have the potential to improve quality and safety, patient treatment, increase efficiency and reduce the costs of healthcare. However, it has become increasingly evident that introducing EPR systems comes with serious patient safety risks. In June, Patient Safety Learning held a virtual roundtable session with a group of experts who had been affected by EPR issues. Together, they discussed the patient safety risks and avoidable harm associated with these systems. Those collaborative conversations became a catalyst for our new report, in which we set out ten principles that aim to put patient safety considerations at the heart of the design, development and rollout of EPR systems. The report gained interest across digital publications, social media and national news, and crucially with key stakeholders in healthcare. A great example of how the collaborative discussions from a roundtable event can help instigate further debate. Earlier in the year, we worked with AQUA to facilitate a workshop (hosted by the Royal College of Surgeons of Edinburgh) for Patient Safety Partners and their managers. With the Patient Safety Partner role only being introduced recently, we wanted to gather those who had rapidly become experts through experience, to share their early insights and learning. Conversations were rich and varied, but the overall focus of the day was to start to identify ‘what good looks like’ in relation to embedding the role effectively. A number of themes were covered including recruitment and induction, role clarity, influencing and impact. We captured these conversations in a series of blogs which have now formed part of our recently published Patient Safety Partners toolkit of resources. We have received overwhelmingly positive feedback on the toolkit, designed to help Patient Safety Partners, their managers and anyone interested in embedding the role well. The power of community the hub is home to a growing number of networks for people involved in patient safety, including patient safety managers and specialists, Patient Safety Partners and organisational leaders with patient safety expertise and responsibility. These communities of interest are forums that provide peer support, sharing of knowledge, and examples of good practice from the ‘patient safety frontline’. Building on conversations taking place in the network meetings, we worked with the Patient Safety Management Network and the Patient Safety Education Network to plan an event. In the autumn this came to fruition, and we held our first Patient Safety Symposium focused on implementing the Patient Safety Incident Response Framework (PSIRF) tools and methods. We also launched a new book at the event - ‘The emerging applications of safety science’, a wonderful collaboration with many contributors. The event provided a fantastic opportunity for people to come together and have more of those energetic network conversations and share valuable insights in person. Together, attendees were able to work through, and learn how to apply those ‘how to’ tools. It was great to have such a diverse range of participants at this event. One table featured student nurses, a representative from NHS England, a GP and a senior director from an independent trust. This was a genuine and much valued flattened hierarchy that enabled confident engagement and shared learning. Feedback was very positive with many people highlighting the value of working collaboratively on the day, and beyond. “It was an excellent networking opportunity, and I have since been in contact with a new peer. We have shared our current Patient Safety Incident Investigation reports and provided a critical friend approach to each other.” Attendee. Feedback on being part of the Patient Safety Management Network also highlights the impact of their regular meetings: "The network has been an excellent platform to learn from peers across the country. I have not come across any other platform such as this. I use it as my go-to for practical problem-solving ideas and there are always plenty of them, for all sectors.” Patient Safety Specialist at an Integrated Care Board. The collective wisdom and innovative thinking that emerges from the networks highlights the power of community when it comes to making progress in patient safety. It is unsurprising perhaps that we are increasingly being approached by NHS England and other key patient safety stakeholders who are seeking to collaborate with the networks we support. This presents valuable opportunity to feed that collective frontline wisdom into wider policy development. Patient focused collaboration At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for change and in holding the system to account. Our editorial team has worked with many people who have been directly or indirectly impacted by unsafe care and want to share their insights to inform positive change. Their voices and experiences provide a powerful source of knowledge, and we are grateful that so many have felt able to share these with us through the hub. With an increased emphasis on patient and family involvement in patient safety in the NHS, we are beginning to hear more examples of staff and organisations actively seeking ways to listen to the views and insights of patients. Embedding the Patient Safety Partner role will be key to enabling this. In a presentation for the hub, Lea Tiernan, Patient Safety Engagement Manager, and Armine Afrikian, a Patient Safety Partner, explain how they have worked together to develop the role at Imperial College Healthcare NHS Trust. It provides an excellent example of how trusts can work truly collaboratively with Patient Safety Partners and support them to influence safety at a strategic and operational level. There are many people and organisations working hard to evidence the power of engaging patients in safety improvements and research. This year, we spoke to Anthony O’Connor, who explained the benefits of co-production and listening to lived experience, in two blogs for the hub. We also worked with UK charity Sands, to shine a light on their listening project. Julia Clark and Mehali Patel from their research team draw on the project to illustrate the value of working with bereaved parents. Julia and Mehali explain why hearing and amplifying these unique insights is vital to developing safer, more equitable neonatal and maternity care. In a blog for the hub, Miriam Levin from Demos highlighted the findings from their report “I love the NHS but…” Preventing needless harms caused by poor communication in the NHS. The report looked at everyday harms caused to people as they move through the NHS and try and get the care they need. Demos spoke to 2000 patients and staff about their experiences of health and care, and poor communication from the NHS came out as a significant issue for many people. Summary It is clear that a variety of voices, experiences and expertise is hugely beneficial when it comes to making progress in patient safety. At Patient Safety Learning we continue to proactively seek opportunities to collaborate with others, share individual and collective insights through the hub, and influence key stakeholders and policies. Over the coming months no doubt the networks and the hub will continue to thrive, fuelled by the power of collaboration and the many voices that contribute. As people come together to address patient safety challenges, our collective understanding and knowledge around potential solutions can only deepen and refine – paving the way for a patient-safe future. Join the hub Do you have insights to share around patient safety? Are you a member of the hub? Why not join our global community today (it’s free and easy to sign up). When you’ve registered, you’ll be able to submit an article, share a resource, start conversations in the forum and collaborate with other members. You’ll also have the option to request to join the networks we support. Related content Developing the Patient Safety Partner role: Imperial College Healthcare NHS Trust share their approach Patient engagement resource section on the hub Collaborating for safety: We need to make space for each other NHS England and NHS Improvement: Framework for involving patients in patient safety (29 June 2021)

The three national pharmacy boards at the Royal Pharmaceutical Society (RPS) identified medicines shortages as a key policy area that is impacting patients, pharmacy teams, clinicians and wider groups throughout the NHS. As a result, in January 2024, RPS commissioned a report into medicines shortages. This report is the culmination of extensive engagement and collaboration with patients, the pharmacy profession, wider healthcare professionals and the key local, regional and national stakeholders integral to ensure the continuity of medicines supply. The report concludes by setting out 19 recommendations. Recommendations UK National Policy Recommendation 1: Publish a UK-wide strategy for shortages The UK government should develop a cohesive cross-government and NHS strategy to improve medicines supply chain resilience and medicines security in the context of changing pharmaceutical market dynamics and the ongoing increases in medicines shortages globally. The strategy should incorporate current national policy, ongoing work and existing measures, and create greater alignment in managing shortages across primary and secondary care. Recommendation 2: Recommendation 2. Support UK manufacturing infrastructure for medicines The Government should boost UK medicines manufacturing infrastructure, in both commercial and NHS manufacturing units –particularly generic manufacturing, which accounts for 80% of medicines prescribed in the NHS. UK manufacturing infrastructure offers the potential for a more rapid response from manufacturers to help mitigate acute national medicines shortages. Recommendation 3: Flexibility in existing medicines regulations to speed up access Building on the learning applied during the COVID-19 pandemic, existing and potential regulatory flexibilities should be explored with the MHRA. Recognising that nothing should be done to undermine the purpose of regulation, timely opportunities to flexibly use existing regulations in acute supply challenges associated with national shortages should be identified. For example, enabling medicines manufacturers to reactivate dormant market authorisations more rapidly so they could potentially supply medicines in acute shortage. Recommendation 4: Make better use of pharmacists’ skills The Government should enact legislation to enable community pharmacists to make minor amendments to prescriptions in line with existing hospital practice, RPS policy and the recommendation of the Health and Social Care Select Committee report into pharmacy. Organisations, professional bodies and regulators should identify where pharmacist prescribers can use their prescribing qualification to help manage the impact of medicines shortages on patients and develop pathways to enable this role. Recommendation 5: Reiterate the legal and ethical responsibilities of the supply chain Organisations and professionals in all parts of the supply chain, from manufacturers to wholesalers, pharmacists and prescribers, should understand their responsibilities to patients to enable appropriate, equitable and ethical access to medicines. The 2013 guidance published by the Department of Health Supply Chain Forum – Best practice for ensuring the efficient supply and distribution of medicines across the supply chain (2013) – should be refreshed (or an equivalent developed) and re-promoted to reinforce the behaviours expected in all parts of the supply chain. Recommendation 6: Review the community pharmacy contractual framework The community pharmacy contract in each of the UK nations should be reviewed to ensure that, while acknowledging a pharmacists professional and contractual responsibilities, it minimises the risk of individual contractors incurring a potential loss on the purchase of medicines and supports a stable supply of medicines to patients. Predicting, reporting and responding to shortages Recommendation 7: Earlier reporting of shortages by Marketing Authorisation Holders Timely and accurate information on supply disruptions and shortages should be provided by medicines manufacturers. Marketing Authorisation Holders should work with DHSC to find ways to improve the reporting of medicines shortages and the provision of ongoing information to help mitigate shortages, with a focus on early and consistent information sharing. Developing a more meaningful performance management approach to reporting that promotes good practice, distinguishes between planned and unexpected shortages and actively penalises repeated poor performance would facilitate this. Recommendation 8: Enable greater data sharing to support planning and predict demand The NHS and manufacturers/wholesalers should proactively collaborate to share data, for example, NHS data that enable manufacturers/wholesalers to better predict demand for their products and manufacturer/wholesaler supply chain data that enable the NHS/DHSC to proactively manage the medicines supply chain to minimise disruption and increase resilience of supply. Information flows Recommendation 9: Expand and develop information cascades Information cascades about medicines shortages from DHSC and relevant NHS national medicines supply teams to the wider healthcare system should be reviewed to ensure that they are reaching the right people at the right time. All organisations that cascade or need to act upon information about national shortages should review and develop systems to ensure that information is cascaded to and accessed by those that need it. Equally, healthcare professionals should be aware of their responsibility to access this information and act promptly. Recommendation 10: Further Involve patient groups to support information sharing Patient groups should be a fundamental part of information cascades to facilitate the appropriate sharing of consistent and accurate information to patients. This will enable patient groups to provide support for patients experiencing acute national shortages of their medicines. Recommendation 11: Fund, promote and develop the DHSC/NHS Medicines Supply Tool The DHSC/NHS medicines supply tool hosted on the SPS website (sps.nhs.uk). should be the single source of accessible, consistent, accurate and rapidly updated information about medicines shortages for healthcare teams across the UK. As well as promoting the current tool more widely to healthcare teams, its utility should be increased. There should be funding for the integration of the tool into prescribing systems to alert prescribers to shortages and enable alternatives to be prescribed in real time to provide proactive updates, for example, when medicines are no longer in shortage, and to developing an app-based format to enable easier access to the information. Recommendation 12: Improve systems that provide timely information at the point of dispensing Wholesaler and community pharmacy IT systems should be developed to provide resupply dates for medicines out of stock to enable more meaningful communication with patients and help pharmacists to more rapidly distinguish short-term supply disruptions from national shortages. This is only possible with the provision of accurate and timely information from medicines manufacturers. Local systems Recommendation 13: Develop patient-centred pathways to manage shortages in local systems Continuity planning in local systems should account for the resources required for healthcare teams to manage medicines shortages. Local systems should have protocols for the management of a medicines shortage that works across a locality, particularly between GP surgeries and community pharmacies, to ensure that they continue to minimise the impact of shortages on patients and do not exacerbate health inequalities. Recommendation 14: Invest in the resources needed to manage medicines shortages NHS organisations should review whether they have sufficient resources in pharmacy teams to mitigate and manage medicines shortages. Any investment required needs to be weighed against the opportunity costs of healthcare teams managing a shortage and the impact on patients’ health outcomes and quality of life, not just the cost of alternative medicines. Recommendation 15: Develop cross-sector protocols for shortages of life-critical medicines Cross-sector emergency protocols for life-critical medicines where patients have no alternative treatment should be developed. This will require collaborative working across local systems and the use of regulatory flexibility to allow medicines to flow between primary and secondary care. There should be national/regional oversight to ensure this happens. Recommendation 16: Fund and recruit regional procurement specialists to work across sectors In England, NHS specialist pharmacy services’ regional network of procurement specialists should be funded to work with ICBs to facilitate the development of cross-sector approaches to acute medicines shortages. In Wales, Scotland and Northern Ireland, equivalent arrangement should be established. Recommendation 17: Prioritise supply chain resilience within secondary care contracts Supply chain resilience measures and management of lead times should be further developed and incentivised in awarding secondary care and homecare contracts, which should be proactively managed with suppliers to minimise avoidable causes of supply disruptions. Education, training and research Recommendation 18: Educate healthcare professionals, patients and the public on shortages Joint education programmes for healthcare professionals should be developed to support wider understanding of how UK systems operate end-to-end to mitigate and manage medicines shortages, and highlight common misconceptions about their causes and how to manage them. This will improve transparency and understanding across the supply chain and improve opportunities for shared education and training. All pharmacy teams and students should be trained in where to find accurate information about medicines shortages, and in how to have proactive, informed and supportive conversations with individual patients and the wider public regarding medicines shortages. Recommendation 19: Understand the economic cost of shortages to healthcare organisations and systems The research base on the costs of medicines shortages should be developed to inform resourcing decisions and underpin investment in resources and the implementation of quality improvement programmes. This should include not just the cost of alternative medicines but the wider costs to the healthcare systems and the clinical impact on patients in terms of their health outcomes and quality of life. Recommendation 20: Understand the impact of speculation and digital purchasing systems on the supply chain Further work needs to be done to understand the extent to which speculation exists within wholesale and medicines brokering activities and the extent to which the use of automated purchasing platforms is disrupting demand prediction and purchasing patterns. These factors have the potential to confuse the issue of medicines shortages locally. Read the full report on the Royal Pharmaceutical Society's website via the link below.

Amanda Wynn is an independent consultant, researcher and trainer based in Cambridgeshire, specialising in older and disabled survivors of domestic abuse and sexual violence. In this blog, Amanda talks about her recent research into sexual assaults against older people by hospital staff. She shares an overview of her findings and calls for greater awareness and support. Motivated by a patient death I undertook my first research into sexual assaults against older people by hospital staff in 2021, after reading about the horrific case of an older patient who died from internal haemorrhaging due to severe vaginal injuries. A member of staff was arrested on suspicion of rape, but ultimately was not charged. I found it staggering that more people weren't aware of what happened to this lady. After placing a post saying as much on social media, I received messages indicating that this wasn't the isolated case I assumed it was. I was curious to know how often older people in hospital are being sexually assaulted by staff - people in positions of trust who should be caring for patients. So, I decided to find out for myself. The findings: increasing numbers, bias and poor support As I don't receive any funding for my research, I had to rely on freedom of information (FOI) requests to get data from NHS England trusts. I looked at the number of incidents reported to staff and recorded on the hospital’s incident system over a 5 year period, from 2016/17 to 2020/21 (financial years). My first paper highlighted at least 75 incidents of sexual assault against patients aged 60+ in NHS Hospitals in England, where the alleged perpetrator was a member of staff. I was surprised by the numbers but also at the responses to the follow-up questions I asked about support for these survivors. In the vast majority of cases, there was no referral to specialist services. Only 21% (16) of the incidents recorded were reported to police. Of these 16, all but two had ‘no further action’ taken. I don’t have the data on how the other two progressed so it is unclear whether any convictions were made. I was keen to review the data to see if anything had changed, so I undertook a similar research project in early 2024. This time, the number of reported incidents was much higher over a shorter reporting period (at least 274 incidents over three years). Once again, the number of victims being referred to Sexual Assault Referral Centres or specialist support was very low. Responses to both sets of FOI requests included anecdotal comments from professionals making worrying assumptions about the reliability of people with dementia when disclosing sexual assault. It was also interesting to note that male victims in reported incidents had a higher prevalence than male victims of sexual assault in general - potentially highlighting an increased risk of sexual assaults against older men in hospital. Limited data but a sad fundamental truth Due to lack of funding for my research, I was able to merely touch the surface and report only quantitative data. That means I am unable to determine if the increase in the number of reported incidents is due to more sexual assaults against older people happening. Or if improved reporting and data recording methods can account, either fully or partially, for the increase. However, what is clear is that older patients in hospital are at risk of sexual assault from the very people who should be assuring their well-being and safety. Opportunity for positive change to reduce harm The main aim of my research is to raise awareness of the issue among front-line professionals. Whilst this can include the potential perpetrators, most will be the people who are best placed to stop such incidents, and to ensure an appropriate response when an incident is reported. NHS England has strengthened its approach to domestic abuse and sexual violence in recent years with duties placed on staff to record and report incidents. There may still be some complacency about how genuine patient reports are though, and therefore less emphasis on support. It's also important for both health care staff and the general public to be aware that sexual assaults in hospital do happen. More awareness of the issue will hopefully lead to more survivors being able to disclose and getting the right support when they do. I would like to develop some training for health and social care staff around responding to disclosures of sexual assault and violence from older people - this will likely be in an eLearning format - but I am keen for access to the training to be free. Too much essential knowledge sits behind paywalls making it prohibitive for the target audience to access. I have the content, but if anyone can help with a platform for hosting and developing online training it would be great to hear! You can contact me at [email protected] if you would like to hear more about my research or the online training. Hopes for the future I would like all health and social care workers to be much more aware of sexual assault against older people - not just in hospitals but in care homes and the community too. Funding for services needs research and data to back it up - my research only touches the edge of the issue and it would be great if more research and eventually specialist support for older survivors of sexual violence can lead on from it. I’d just like to add that I'm really grateful to Hourglass for publishing my research to help get the word out as wide as possible. And, of course, to Patient Safety Learning for giving me the opportunity to share the findings too. Related reading Sexual violence and assault against older people in NHS hospitals in England (2024) Doctors practising despite sexual assault and rape allegations Hundreds of social care residents allegedly sexually assaulted, watchdog reveals Share your insights If you would like to comment on this article or any of the articles published on the hub, please sign up here (for free) and contribute your thoughts and insights below. If you'd like to write about a patient safety issue, experience or improvement project, please read our guide to writing a blog, or contact the editorial team at [email protected].

Sandra Igwe is the Founder and CEO of The Motherhood Group and author of the bestselling book "My Black Motherhood: Mental Health, Stigma, Racism and the System". She served as Co-chair for the National Inquiry into Racial Injustice in Maternity Care and is also a Topic leader for Patient Safety Learning’s hub, with a focus on Black Maternal Mental Health. In this interview Sandra tells us about a new partnership project, bringing together The Motherhood Group, Centre for Mental Health, and the Maternal Mental Health Alliance to address critical gaps in Black maternal mental healthcare. Sandra, you are a Founder and CEO of The Motherhood Group and author of a bestselling book "My Black Motherhood: Mental Health, Stigma, Racism and the System". You served as Co-chair for the National Inquiry into Racial Injustice in Maternity Care and Partner for the Mayor of London's Anti-Racism Hub. And you are, of course, a Topic leader for Patient Safety Learning’s hub. Can you tell us any more about yourself and what motivates you? I am a proud mum to three beautiful girls - an eight-year-old, a six-year-old, and an almost nine-month-old baby. I'm deeply passionate about bridging the gaps between Black mothers and the healthcare system, using my voice in any capacity to improve maternal health outcomes in the UK. At my core, I'm simply a driven mum who can't stand injustice, who loves creating safe spaces for other mothers, and who's brave enough to say the things many Black mothers want to, but are too afraid to voice. Why was The Motherhood Group founded? The Motherhood Group was founded in response to the stark disparities in maternal health outcomes for Black women in the UK. Research consistently shows that Black women are four times more likely to die during pregnancy and childbirth compared to white women, while experiencing higher rates of complications and poorer mental health outcomes. These disparities stem from systemic issues including lack of culturally competent care, implicit bias in healthcare settings, and barriers to accessing mental health support. We established The Motherhood Group to create a comprehensive support system that addresses these critical patient safety issues through advocacy, education, and direct support. Our approach focuses on both supporting Black mothers and educating healthcare providers to deliver more culturally competent care. What have been your key achievements since The Motherhood Group was established? Our achievements demonstrate our commitment to improving patient safety and maternal health outcomes: Reached and supported 12,721 Black mothers through our events, workshops, and peer support sessions. Delivered cultural competency training to 2,991 healthcare professionals, improving their ability to provide safe and appropriate care. Facilitated 742 peer support events and projects. Established partnerships with 3,088 organisations and charities. Coordinated five annual Black Maternal Mental Health Week UK campaigns, with our most recent event attracting over 1,200 registrations. Commissioned by Southwark Maternity Commission to engage with over 750 Black mothers and healthcare practitioners on improving outcomes. Successfully launched the Black Maternal Health Conference UK, consistently drawing over 1,000+ attendees. Can you tell us more about your new partnership project? We're thrilled to announce our Black Maternal Mental Health Project. This ground-breaking partnership brings together The Motherhood Group, Centre for Mental Health, and the Maternal Mental Health Alliance to address critical gaps in Black maternal mental healthcare. Our vision is to delve deeper into the mental health aspects of Black motherhood than ever before. We aim to uncover and address the complex intersections between racial trauma, systemic barriers, and maternal mental health. This includes creating safe spaces where Black mothers can openly discuss mental health challenges without fear of judgment or stigma. We're particularly focused on developing culturally responsive mental health support pathways that acknowledge the unique experiences of Black mothers. By bridging the trust gap between healthcare systems and Black mothers through evidence-based interventions, we hope to transform how perinatal mental health services engage with and support Black mothers. Our comprehensive approach will demonstrate impact across community engagement, healthcare provider education, policy influence, cultural competency enhancement, and peer support network development. Through this work, we aim to create lasting systemic change that improves the mental health outcomes for Black mothers across the UK. What will be your areas of focus? Through this project, we will conduct comprehensive research exploring multiple dimensions of Black maternal mental health: We will investigate the profound impact of pregnancy loss on mental health through our collaboration with Tommy's Miscarriage Support Tool, examining how we can better support Black mothers through these challenging experiences. Our partnership with South East London Mind will enable us to explore how creative expressions through music and art can serve as powerful therapeutic tools for Black mothers' mental wellbeing, providing alternative pathways for emotional healing and community connection. Through our Black Maternal Mental Health Week webinar series, we're creating platforms for open dialogue about mental health challenges specific to Black mothers, while our Black Maternal Health Conference outcomes provide crucial insights into systemic barriers and potential solutions. The Black Mums Connect co-production phase will ensure that our support services are directly shaped by the voices and experiences of Black mothers, while our Southwark Maternity Commission engagement allows us to influence policy at a local level. Our collaboration with Genomics England brings a vital scientific perspective to understanding maternal health disparities, and our training delivery with multiple NHS Perinatal Teams helps embed cultural competency directly into healthcare services. The project aims to engage with 1,000 Black mothers and healthcare professionals across all programmes in its first year, demonstrating our commitment to substantial community impact. Will you keep us posted on the outcomes and activity of the Black Maternal Mental Health Project? Absolutely. Transparency and data-driven evaluation are central to our work. We will be documenting our journey and will have our report for Black Maternal Health Conference UK and Black Maternal Mental Health Week UK in September 2025. We're committed to sharing both quantitative metrics and qualitative feedback to demonstrate how our work is improving maternal health outcomes and patient safety for Black mothers. If you would like to keep up to date with the work of the Motherhood Group, the Black Maternal Mental Health Project and details of their upcoming conferences, you can visit the following websites and social media pages: X(Twitter): @motherhoodgroup Instagram: @sandeeigwe @themotherhoodgroup Websites: Black Maternal Mental Health Project - The Motherhood Group - partnership page www.themotherhoodgroup.org www.sandraigwe.com Related hub content Racial disparities in postnatal mental health: An interview with Sandra Igwe the Founder of The Motherhood Group My Black Motherhood: Mental Health, Stigma, Racism and the System (by Sandra Igwe) Saving lives, improving mothers’ care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2020-22 (MBRRACE-UK, October 2024) Five X More report - The black maternity experiences survey: A nationwide study of black women's experiences of maternity services in the United Kingdom (24 May 2022) Muslim Women's Network UK - Maternity experiences of Muslim women from racialised minority communities (12 July 2022)

The Patient Safety Partner (PSP) role was introduced in 2022 by NHS England as part of its Framework for involving patients in patient safety and National Patient Safety Strategy. Patient Safety Partners can be patients, carers or members of the public who want to support and contribute to an organisation’s governance and management processes for patient safety. This webpage brings together a toolkit of resources, designed to share insights and information about the Patient Safety Partner role.  It will be particularly useful for: Patient Safety Partners. Managers of Patient Safety Partners. Organisations who have not yet introduced the role. People that are interested in patient engagement and patient safety. The Patient Safety Partner Network The Patient Safety Partners Network is a group of Patient Safety Partners, in both paid and voluntary roles within NHS organisations. First set up in 2023, the network is supported by Patient Safety Learning and has now grown to over 150 members. Meetings take place monthly and provide a psychologically safe space for peers to discuss any challenges, successes and opportunities for the role. Occasionally Patient Safety Partners invite speakers and this can inform discussions as well as influence policy. If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here (it’s free). Patient Safety Partners can also join the Patient Safety Management Network, which again is free. Members of the networks have access to a private space on the hub, where they are able to share and view resources, read the meeting notes and have conversations with peers between meetings. Early impact of the role Patient Safety Partners: examples of impact: In this blog, we speak to members of the Patient Safety Partners Network, as well as a manager of five Patient Safety Partners, and hear how their work is having a positive influence on patient safety. Spotlight on Imperial College Healthcare NHS Trust Developing the Patient Safety Partner role - Imperial College Healthcare NHS Trust share their approach: An interview with Lea Tiernan, Patient Safety Engagement Manager at Imperial College Healthcare NHS Trust, about how they have developed and embedded the Patient Safety Partner role. Lea explains what they have done practically to support those starting out in the role and to integrate them at a strategic level. Watch an 18 minute video presentation where Lea Tiernan and Patient Safety Partner, Armine Afrikian, talk about how they have worked hard to develop the role at Imperial College Healthcare NHS Trust in a meaningful and strategic way: Insight sharing: successes and barriers How do Patient Safety Partners feel about their role? Analysis of online survey results: Patient Safety Partners Anne Rouse and Chris Wardley and Patient Safety Learning’s Chief Executive, Helen Hughes, examine the results of a recent survey of Patient Safety Partners. The results reveal significant variation in how the role is being implemented in NHS organisations in England. Patient Safety Partners – lack of role clarity a barrier for impact: Insights from areas of good practice, where the role has been well support and integrated locally. These examples show how clarity and guidance has helped to remove barriers, enabling Patient Safety Partners to have a positive impact for patient safety, as intended. Patient Safety Partners: recruitment and induction: Knowledge captured in this blog provides guidance to anyone involved in embedding the Patient Safety Partner role within their organisation. It also includes advice for Patient Safety Partners to help them navigate their new role, settle in and have a positive influence on patient safety. Patient Safety Partners: influencing for safety: Includes some suggested approaches and actions that Patient Safety Partners and trusts might take to help the role have greater influence and impact. Patient Safety Spotlight Interview with Mark Smith, National Patient Safety Partner and South West Yorkshire Partnership Foundation Trust: Mark explains the important role that PSPs play at national, regional and local levels of the healthcare system and identifies key opportunities and challenges they face in bringing the voice of patients and families at a strategic level. Patient Safety Partners - A workshop at Kingston Hospital: Summary of a workshop for Patient Safety Partners at the Kingston NHS Foundation Trust. The insights in the above articles are drawn from various sources including Patient Safety Partner Network discussions and a recent workshop co-run with AQUA and kindly hosted by the Royal College of Surgeons (Edinburgh) at their Birmingham Office. Blogs authored by Patient Safety Partners Individual Patient Safety Partners are also sharing their insights and personal reflections via the hub. Staff fatigue and the impact on patient safety 'Safety cases' in the NHS – the example of hospital capacity East London NHS Foundation Trust: World Patient Safety Day SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect? Supporting veterans and their dependants in primary care We hope this will lead to greater awareness of the role, the challenges and impact, and encourage interest from clinicians, patient safety leads and potential Patient Safety Partners. If you would like to contribute a to the hub, please get in touch with us at [email protected] or read our guide to writing a blog. NHS links and resources The NHS Patient Safety Strategy Framework for involving patients in patient safety Compassionate Communication, Meaningful Engagement The Primary Care Patient Safety Strategy You’ll need to be logged in to the NHS Futures platform to access the below resources: Enabling PSP inclusion and enhancing diversity National PSP remuneration and expenses step by step National Patient Safety team PSP FAQs National PSP Mentor Handbook National PSP mentors training and resources guide PSP Wellbeing Plan Attachments: Involvement Payment and Expenses – a guide for Patient Safety Partners and patient safety team programme areas: 20230721PSP_PPVremunerationandexpenses(2).pdf Patient safety partner frequently asked questions (FAQs): 230802NationalPSPFAQsver2.3(2).pdf Newsletters Patient Safety Partners bulletin – a monthly bulletin produced by NHS England Patient leadership newsletter NHS England e-mail bulletins page Preventable Deaths Tracker Share your insights Are you involved in introducing Patient Safety Partners to your organisation? Or perhaps you are a recently appointed Patient Safety Partner? Did you find this toolkit useful? What other information would help you? If you'd like to share your feedback, or your insights on the Patient Safety Partner role, you can comment below (sign up here first - it's free to join the hub), or you can contact us at [email protected].

In this anonymous blog, a patient reflects on her recent appointment with a women's health expert. After decades of enduring both long-term debilitating symptoms and a history peppered with poorly recorded health incidences, she says that she finally felt 'seen'. She argues that investing in longer, women's health consultations like this would likely save the NHS money by reducing inefficiencies and improving outcomes.  I have just got off a call with a GP and women's health expert, and after more than 20 years worth of symptoms and events I finally feel seen and heard. I am 41 years old and have never received any private healthcare treatment before today. During my life, I have been seen by some of the most compassionate, skilled and effective NHS healthcare professionals. My closest friends and family work for the NHS and are brilliantly determined and patient-focused. I have however also been seen by some of the most dismissive and ineffective healthcare professionals, many of these during appointments relating to gynaecological or female-focused issues. As I relayed my full history via video call to the GP today, I became quite emotional. The experiences I recounted of the healthcare' provided to me during teenage years, early postpartum hours, an IUD insertion, perimenopausal symptoms, concerning and debilitating gynaecological symptoms, and a year-long-wait for a gynaecological referral, all carried a level of trauma. Talking about them made me realise how I had been repeatedly let down, dismissed or inappropriately treated. Key points: looking back at my history I had not been offered local anaesthetic for an IUD procedure where I should have been, and I went on to feel extremely high levels of pain (which had not been recorded in my notes). Going by my description, it was likely after giving birth that I had experienced a postpartum haemorrhage, which had not been recorded or treated appropriately. A internal scan that had been deemed unnecessary and cancelled, should have been done to investigate key causal factors for some of my gynaecological symptoms. I had made the private appointment because I knew this woman was a well known expert in the full spectrum of women's health issues. I wanted guidance that came from a place of knowledge and passion. I wanted the next steps I took to be the right ones for my health. I wanted to understand what my array of symptoms meant and the role my medical history had to play. I wanted to make sure I, and my regular GP weren't missing something important. I wanted to feel better. Can most people afford to access this service? No. Can I afford to do it again? No. Was it worth every penny? Absolutely for me personally, but the NHS will benefit too. Key points: looking at next steps She gave me advice for which investigations and blood tests were needed to be able to determine the causal factors of my gynaecological symptoms. She confirmed many of my symptoms related to perimenopause and provided an explanation as to how this was affecting my body. I was given a breakdown of options for HRT and advice on which to try first - explaining carefully which element of the treatment addressed which of my symptoms. I came away with so much support, guidance and knowledge that I can honestly say this appointment, which had taken at least 6 times as long as an NHS slot, would undoubtedly save the system money in the long run (considering the multiple appointments I'd had over the years). And more importantly, I am confident it has set me on the path to receive the right investigations, symptom management and treatment options. These two points obviously go hand-in-hand when striving for an efficient health care system that gives value for money and leads to improved outcomes. Was it because she is a private doctor and provides a better service? Of course not. She simply had the right expertise, attitude and, crucially, time to properly navigate my health needs. She works for the NHS too. While she spent much longer with me than an NHS GP would have been able to, I do feel this sort of approach could actually save the NHS time and money if they were to offer longer consultations for women's health issues. I came away understanding my health better, armed with knowledge that would help guide the next steps of my health journey in a way that would be more efficient for the healthcare professionals I would be communicating to. In just 40 minutes... In just 40 minutes (it took far less time than we had allotted) she had done 6 key things: listened to my summary of 30 years worth of events and relevant history (I had put this in writing for her to read at the start, which I felt would aid us to use the time efficiently) asked many questions to gain further detail...and listened found time to medically explain my symptoms and likely causes, in plain English offered next steps advice communicated with compassion and respect made notes that would form the basis of a letter for my GP. I am an assertive and confident person, but reflecting on my appointment and the events I retold, I realised there was a common and surprising theme running through. Whenever something hadn't felt right with my body, I had felt uncomfortable speaking up. Or I had very quickly accepted a poorly executed follow-up or a dismissal of my concerns entirely. This resulted in long-lasting symptoms and traumatic healthcare experiences being accepted. Two things that I had learnt to endure, to the detriment of my health. We have got to help girls and women of all ages feel confident and enabled to speak up about their health. From an early age they need to hear us all (men and women) using the right language, with no shame. Only then can we set girls up to confidently advocate for themselves and their own health. But confidently speaking up isn't enough if no one listens. We need to really listen to girls and women. Not just for the obvious reasons of humane and compassionate treatment, but also because it is more efficient for the system. And let's be honest, medical history somewhat shafted us, so the data that lies within women's experiences should be welcomed and encouraged if we are to have any chance of catching up. Only by genuinely hearing, respecting and responding to their voices and their experiences relating to their bodies, can women be enabled to influence the diagnostic and care planning process. A process that surely we should be central to? Related reading The normalisation of women’s pain Sex bias in pain management decisions Misogyny is a safety issue: a blog by Saira Sundar Medicines, research and female hormones: a dangerous knowledge gap Dangerous exclusions: The risk to patient safety of sex and gender bias Unconscious bias: gynaecological pain, the elephant in the womb! Pain bias: The health inequality rarely discussed