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A recent white paper, Clinical Competency in the Age of AI,  presents findings from a systematic narrative synthesis of 445 studies examining clinical competency requirements in AI-augmented healthcare. It addresses a structural gap in how current competency frameworks prepare clinicians for AI-assisted practice. In addition to examining the breadth of research into clinical risks associated with use of AI in clinical care, the research analysed 23 existing AI competency and capability frameworks, including the NHS Health Education England AI and Digital Healthcare Technologies Capability Framework and the DECODE international consensus framework. It found that across all reviewed frameworks, the competencies most critical for frontline patient safety—critical appraisal of AI recommendations, detection of biased outputs, governance escalation, and protection of professional moral accountability—are largely limited to awareness statements for frontline users. Clinicians are expected to understand what AI is. They are not equipped to practise safely with it. The white paper proposes a five-domain competency framework, specified across three career stages, that translates intersecting AI risks into assessable clinical capabilities for practising clinicians. Key findings AI erodes clinical reasoning without competency safeguards. The Budzyń et al. (2025) multicentre colonoscopy study provides the first real-world evidence: adenoma detection rates fell from 28% to 22% among endoscopists after three months of AI assistance. The skill had not been assessed. It had not been exercised. It had atrophied. Cognitive overload drives uncritical AI acceptance. Alert override rates of 90–96% have been documented in deployed clinical AI environments—a workforce adapting to unsustainable demand by reducing evaluative effort. AI tools assessed as safe under controlled conditions carry significantly higher risk in busy, overstretched environments where they are most needed. Governance infrastructure is inadequate. Over 70% of NHS trusts lack documented clinical safety assurance for deployed AI tools (Oskrochi et al., 2025). Clinicians in these settings carry full personal professional accountability for AI-assisted decisions without the institutional infrastructure that should underpin them. Risks compound, but are treated as parallel separate risks. Time pressure increases automation bias severity. Automation bias accelerates deskilling. Deskilling undermines safety governance capacity. Equity failures concentrate where burnout is highest and training resources most limited. Current frameworks miss these feedback loops. Healthcare-specific competency frameworks are insufficient. Over 75% of medical students receive no formal AI education. Where training exists, assessment tools lack specificity for healthcare contexts. This research defines what AI clinical competency requires: technical understanding, critical appraisal, equity awareness, safety governance knowledge, and professional identity maintenance, integrated rather than treated as separate modules. Implementation guidance remains fragmented. Governance frameworks address safety. Education frameworks address training. Workforce research addresses burnout. Each treats its domain rigorously while missing the system dynamics. This research consolidates evidence into practical principles for curriculum development, organisational deployment and regulatory strengthening. Harm concentrates in those least able to detect it. The populations most at risk from biased AI outputs are served by clinicians least equipped to recognise that bias, in settings least able to monitor it. This convergence is structural and will not be resolved by improving AI performance alone.

Last month, Public Policy Projects hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients.  In this article Patient Safety Learning reflects on a discussion at this event between a panel of experts to discuss the ambitions set out in the NHS 10 Year Plan and what it means for patient voice and patient safety. At the heart of the discussion was a simple but important question: are patients truly at the centre of the system, and how do we make sure their voices lead to meaningful change? A positive shift towards patient choice The NHS 10 Year Plan places strong emphasis on patient choice, agency and feedback. These commitments were widely welcomed by the panel. For many working in patient safety, the idea that patients should be central to their own care has long been a core principle. Giving patients greater choice and making it easier for them to share their experiences is a positive step. It reflects years of calls for healthcare systems to listen more carefully to the people they serve. However, some participants noted that, despite the focus on patient voice, patients themselves were not included on the panel. While there were patients on other panels during the conference, there was surprise that a patient safety partner or patient safety advocate had not been invited to contribute directly to the discussion. This absence highlighted a key tension: even when patient perspectives are recognised as vital, they are not always embedded in the decision-making or discussion processes themselves. However, while the overall direction of travel is encouraging, the discussion also highlighted areas where the 10 Year Plan could go further. What’s missing from the conversation? Although the plan speaks clearly about choice and feedback, it is less explicit about patient innovation, co-production and the experiences of harmed patients. These are crucial areas in patient safety. Patients and families often hold unique insights into where care has gone wrong and how it could be improved. When those perspectives are included early in improvement work, they can shape safer systems. Panel members felt these aspects need clearer recognition if the ambition of truly patient-centred care is to be realised. Trust, independence and the Dash Review The conversation also touched on Dr Penny Dash’s review of the patient safety landscape, published last year, shortly after the 10 Year Plan. The review included a number of proposals with direct implications for the visibility and independence of patient voice at a national and system level. This included plans to bring patient feedback mechanisms “in house” within a new patient experience directorate and moving functions of Local Healthwatch into Integrated Care Boards and providers. While this may improve efficiency, it raised concerns about independence and trust. If feedback systems are managed solely by the organisations being complained about, patients and families may feel less safe raising concerns. Independence plays an important role in ensuring transparency and confidence that concerns will be taken seriously. Maintaining that trust is essential if feedback is to remain open, honest and useful for learning. Are patient experiences just “stories”? Language became an unexpected but important theme. Patient experiences are often referred to as “stories”. While this language can humanise healthcare and highlight the real impact of harm, the panel reflected on whether the term always serves patients well. Referring to experiences as stories can unintentionally imply anecdote rather than evidence, potentially diminishing the seriousness of harm. The panel was asked a simple question: which patient story has actually led to meaningful change? When change only happens after escalation Paula Sussex, the Parliamentary and Health Service Ombudsman (PHSO), shared an example of a complaint that reached Ombudsman level. In that case, input from both the patient and the organisation led to significant improvements. It demonstrated the power of the patient voice when it is truly heard. But it also raised an uncomfortable question: should change only happen once a complaint escalates to that level? If meaningful improvements rely on escalation, it suggests earlier opportunities to listen and learn may have been missed. A similar example was shared by Norma Findley from Seating Matters, who described how a large legal claim had acted as the catalyst for organisational change. Again, the discussion returned to the same point: should it really require litigation and serious harm before learning happens? Too often, patient voices seem to gain traction only once they enter a formal or adversarial process. A more proactive model in maternity safety Louise Pye from the Maternity and Newborn Safety Investigations (MNSI) programme highlighted a different approach through their work around HEART and HEWS: HEWS: Health Equity Warning Score – this has been developed to classify a person’s risk of experiencing barriers to health equity. HEART: Health Equity Assessment and Resource Toolkit – this goes beyond HEWS and provides prompts and questions in relation to a person’s protected equality characteristics and social determinants. By using HEART and HEWS, MNSI aim to ensure that their investigators make safety recommendations and prompts to NHS trusts that focus on health equity to ensure that they consider personalisation in all areas of maternity care. Here, engagement with families is built into the investigative process from the beginning, rather than being added afterwards. Louise suggested that healthcare needs a clear and consistent model for working with patients and families — one that is embedded, compassionate and applied across organisations. The importance of co-production Chris Graham from Picker emphasised the value of co-production and involving people with lived experience directly in improvement work. Patient feedback can take many forms: Structured feedback Solicited surveys Systematic data collection Each serves a different purpose. For example, feedback collected for regulatory assurance may be very different from feedback intended to inform service redesign. Being clear about why feedback is collected makes it far more useful. Complaints as a gift Returning to the role of complaints, Paula Sussex explained how the PHSO analyses complaint data to identify recurring themes and systemic issues across healthcare. She encouraged organisations to view complaints as a gift, an opportunity to learn and improve rather than something to fear. For this to work, however, organisations must demonstrate visible change as a result of what they hear. Listening alone is not enough. Digital data and the risk of losing the human story The panel also explored the growing role of digital analysis. Large datasets can now be analysed quickly to identify patterns in patient feedback at scale. This can be powerful, helping organisations spot trends that might otherwise be missed. But there is also a risk. When experiences are reduced to coded data points, the emotional and relational context behind them can disappear. The challenge is to balance efficient analysis with preserving the human meaning behind patient experiences. Learning from social media Norma Findley also highlighted the potential value of social media communities, such as Facebook groups, as a source of patient feedback. Increasingly, patients are sharing experiences outside formal healthcare channels. These spaces can offer valuable insights into patient concerns, expectations and emerging issues. Used responsibly, they could help organisations become more responsive and transparent. From listening to action Across the discussion, one message came through clearly: Patients want to be heard — but more importantly, they want to see change. Acknowledging feedback is important, but what builds trust is demonstrable improvement. Paula Sussex also noted that the statutory duty of candour, while well established in policy, is not yet fully embedded in practice. This reflects a broader challenge in healthcare: the gap between policy intentions and lived experience. Key themes from the discussion Several key themes emerged from the forum: Escalation as a catalyst for change - Improvements often occur only once complaints reach Ombudsman level or result in legal action. Independence and trust - Bringing feedback systems in-house could risk reducing perceived independence. Language and framing - The term “patient stories” can humanise experiences but may unintentionally minimise harm. Data versus narrative - Digital analysis offers scale but risks losing context if not balanced with human insight. Co-production and lived experience - Genuine partnership requires structured engagement with patients and families. From feedback to action - Patients want to see tangible improvement, not acknowledgement alone. The implementation gap - Commitments such as the duty of candour are still not consistently realised in practice. A shared commitment to doing better What stood out most from the discussion was a shared commitment to strengthening patient voice and patient safety. The conversation recognised that progress has been made, but also that structural, cultural and linguistic shifts are still needed. Rather than becoming influential only once harm has escalated into a formal complaint or legal process, the patient voice is most powerful when it is: embedded early in improvement work treated with respect and seriousness analysed thoughtfully and linked directly to visible change. If the ambitions of the NHS 10 Year Plan are to be realised, ensuring that patient voices lead to meaningful improvement will remain one of the most important challenges ahead. Share your insights Have you seen the impact of the patient voice in patient safety? Share your thoughts on this article and the issues raised by commenting below (sign up first for free). Or you can email our editorial team at [email protected]. Find out more about the Patient Safety Forum 2026 You can read more about different discussions and panel sessions at this year’s event in the below: Designing AI with patient safety at its core: Reflections from the Patient Safety Forum 2026 Safe systems, safe cultures: reflections from the Patient Safety Forum 2026

This month, the Professional Standards Authority have published their updated and combined Standards for the organisations they oversee and accredit. They are the result of extensive engagement, consultation and careful reflection. The Standards have been revised with one clear aim in mind—strengthening patient safety and public protection through robust professional regulation and registration. In this blog, Amanda Partington-Todd, Interim Director of Regulation and Accreditation, explains why the new Standards are good for patient safety.  Clearer expectations mean safer practice If our expectations of the professional regulators and Accredited Registers are unclear, it becomes harder to deliver them well. One of the most important changes we have made is to improve the clarity of our requirements by refining and streamlining the Standards. Clear standards support better decision making. They reduce ambiguity. And they help organisations focus on what really matters—protecting patients and the public, and maintaining public confidence in the health and care professions. The same safety bar for everyone We now have one single set of Standards for both professional health and care regulators and Accredited Registers. This is important. Different organisations operate in different ways. But when it comes to patient safety, the public should expect the same high standards, regardless of the type of body involved. By aligning our expectations, we are making it clear that the level of protection afforded to the public should not differ, even if regulators have legal powers that Accredited Registers do not. Strong governance and leadership protect patients Research and experience show that organisational culture and patient safety are closely linked. That is why the new Standards place consistent expectations on governance and leadership. Senior leaders must have appropriate oversight of how their organisations are run. They must understand the risks. And they must be accountable for how concerns are handled. Good governance helps create a culture where issues are identified early, concerns are taken seriously, and learning is embedded. That culture directly supports safer care. A stronger focus on risk and safeguarding Regulation exists to reduce the risk of harm. Our revised Standards strengthen expectations around evidence and risk-based decision-making, particularly in relation to professional suitability. This includes clearer expectations around safeguarding and appropriate checks, such as criminal records checks, where relevant. Safeguarding is not a technical requirement—it is fundamental to public safety. By reinforcing proportionate, risk-based approaches, the new Standards strengthen our expectations of how regulators and Accredited Registers assess professional suitability throughout a practitioner’s career, holding them to account for maintaining effective safeguards to protect the public. Better collaboration means fewer missed risks Patient safety can be undermined when information is not shared or when concerns are not addressed early. The new Standards encourage stronger collaboration and alignment across regulatory partners. By working together, sharing relevant information and reducing gaps between organisations, we can reduce the risk of missed opportunities to act. We also want to see concerns resolved as early and as locally as possible, where appropriate. Early action taken locally can prevent problems escalating; for example, by removing barriers to people raising complaints, and improve outcomes for patients and the public. Raising the bar from the very start For organisations applying to join our Accredited Registers programme, we have strengthened the tests we apply at the earliest stage. Improved eligibility requirements and clearer public interest assessments mean we can make the right decisions about which organisations are suitable for accreditation before they enter the programme. This early scrutiny strengthens public protection and supports confidence in the quality of Accredited Registers. Focused on impact, not just process Across all of these changes, one principle runs through the new Standards—regulation must make a real difference. It is not enough to have policies in place. The systems must work. Risks must be identified. Concerns must be handled fairly and effectively. Organisations must be willing to learn and improve. By clarifying expectations, aligning standards, strengthening governance, reinforcing safeguarding and encouraging collaboration, we have built a framework that is sharper, more consistent and more focused on outcomes. Patient safety depends on strong, effective regulation and registration. Our updated Standards are designed to achieve exactly that by driving continuous improvement and vigilance from the regulators and Accredited Registers. This ensures that regulation continues to protect the public and maintain confidence in health and care professions.

On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this. Last week the nurse Lucy Letby was found guilty of murdering seven babies on a neonatal unit at the Countess of Chester Hospital. She was also convicted of trying to kill six other infants at the same hospital between June 2015 and June 2016.[1] She received whole-life order for each offence she committed, meaning she will spend the rest of her life in prison unless under very exceptional circumstances.[2] At Patient Safety Learning our thoughts are with everyone affected by these appalling crimes. It is shocking how this nurse was able to undertake her deliberate acts for so long, and that when concerns were raised the actions taken were not able to prevent multiple deaths and harm. In the wake of this verdict, the Secretary of State for Health and Social Care, Steve Barclay MP, has announced that there will be an independent inquiry into the circumstances behind the murders and attempted murders of the babies at Countess of Chester Hospital.[3] Victims’ families will be invited to engage with and shape this inquiry, which will also look at how the concerns raised by clinicians were dealt with. Understandably, given the horrendous nature of these crimes, this case has received extensive media coverage. In this article we will not seek to replicate this, but instead look towards the future inquiry. Considering the evidence presented to date, we will outline some of the key patient safety themes and issues that we believe should be considered as part of this, especially: Clinicians’ safety concerns and speaking up. Gaps in incident reporting and investigation. Failures in leadership and governance. What type of inquiry should this be? Statutory or non-statutory? Before discussing these three patient safety themes, it is first worth considering the nature of this inquiry. The Government has announced that this will be conducted as a non-statutory public inquiry. Inquiries such as this are established by a government minister, but not under an Act of Parliament. Potentially this allows for the inquiry to be set up and begin its work more rapidly than a statutory inquiry, as it possesses greater flexibility on procedures and is not bound by the rules set out in the Inquiries Act 2005.[4] However, this also means the inquiry will lack the legal power to compel witnesses to give or produce evidence relevant to their work. Concerns have already been raised about the appropriateness of holding a non-statutory rather than a statutory inquiry. Of particularly relevance to these considerations is the recent patient safety inquiry into mental health inpatient care in Essex. In this case, earlier this year, the non-statutory inquiry had to be converted into a statutory inquiry due to the extremely low levels of engagement by staff in this process.[5] [6] Since the announcement of the Lucy Letby inquiry, there have now been further news reports suggesting that the Government may now be reconsidering this decision in the wake of growing demands to put the inquiry on a statutory footing.[7] Patient Safety Learning supports the need for an inquiry at pace, so that learning and action can be taken to prevent future harm at the Countess of Chester Hospital and more widely. We believe that this inquiry needs to be thorough, expert-led and evidence based with insights from families and staff. Given the way that clinicians' concerns about Lucy Letby were handled, it is also important, in our view, that staff are supported and actively encouraged to engage in the inquiry. We believe that a statutory inquiry would be the best way to achieve this and that the families affected by this tragedy deserve nothing less. We support calls from the Chair of the Health and Social Care Select Committee, local MPs and lawyers representing the victims’ families to make this change.[8] Clinicians’ safety concerns and speaking up Turning now to our first key patient safety theme, concerns were first raised about Lucy Letby by the unit consultant, Dr Stephen Brearey, in October 2015. Dr Brearey and other clinicians involved in this case have raised serious concerns about the hospital’s approach to those who raised these issues and a failure to act on their concerns.[9] [10]These experiences mirror patterns we see all too often across the NHS, with organisational cultures deterring staff from speaking up and responding negatively when concerns are raised. We see this reflected year after year in the results of the NHS Staff Survey, which reveal that significant numbers of staff do not feel safe to speak up or confident that their concerns will be acted upon.[11] This theme also emerges time and time again in patient safety inquiries and reviews.[12] Creating a safety culture, where staff feel safe to speak up about concerns, is identified as a core part of the NHS Patient Safety Strategy.[13] As part of its work towards this, NHS England has recently published new guidance for Trusts to help support teams both understand safety culture and support them in improving this.[14] However, despite this work overseen centrally by the Safety Culture Programme Group, it is still unclear:[15] how the implementation of good practice guidance is being monitored and evaluated; and in cases where there are concerns about speaking up practices, what mechanisms are in place, if any, to identify these and, if necessary, indicate the need for intervention by NHS England and regulatory bodies. Following the verdict in the trial of Lucy Letby, NHS England issued a letter to all Integrated Care Boards and NHS Trusts reminding them of existing provisions put in place to ensure staff feel safe to speak up, emphasising that “NHS leaders and Boards must ensure proper implementation and oversight” of these policies.[16] At Patient Safety Learning we believe that simply issuing a reminder about existing guidance falls far short of the action needed to tackle this issue. NHS England have a leadership role in this area, but this feels more like ‘management by press release’, adding little of value other than saying ‘don’t get it wrong’. We also note that in this letter NHS England stated that they had asked Integrated Care Boards to play a role in ensuring effective and accessible speaking up arrangements are in place. Although this may be a welcome suggestion, their role in this area is hampered more broadly by the absence of guidance concerning Integrated Care Systems and NHS Patient Safety Strategy, and their role in patient safety more broadly. As outlined in our recent report, The elephant in the room: Patient safety and Integrated Care Systems, there needs to be far greater clarity about the patient safety responsibilities of Integrated Care Systems and how these fit into the wider healthcare system.[17] We would suggest that speaking up is a key area for the inquiry to explore in further detail. It should consider what action is needed to ensure healthcare has the right culture to hear staff concerns and recommendations for improvements, and to respond fairly and appropriately to those whistleblowing for patient safety in the NHS. The inquiry should consider this in the context of what has been said in previous inquiry reports and recommendations in this area, such as the Berwick review into patient safety, and what NHS organisations need to do to adopt and accept the recommendations for an open and fair safety culture.[18] Gaps in incident reporting and investigation Another key area of concern raised by the Letby case was how incidents were reported and recorded. We understand that deaths were reported to the Trust’s incident reporting system and that the Trust had classified these as “medication errors”, rather than a “serious incident involving an unexpected death”. As a result of this, they were not grouped together as the latter classification would have allowed, which may have resulted in a quicker recognition and investigation of their causes.[19] Concerns were also raised in a Royal College of Paediatrics and Child Health review in 2016 about deaths not being classed as serious incidents and some not sent for post-mortem examinations, despite this being best practice.[9] This review also found gaps in staffing and poor decision-making. Difficulties in monitoring safe performance in Trusts and detecting concerning patterns are not new issues, particularly in maternity care, and were a key problem raised last year by the inquiry into maternity and neonatal services in East Kent.[20] In response to a recommendation of this inquiry, the Government has committed to the prompt establishment of a Task Force to drive the introduction of valid maternity and neonatal outcome measures, aimed to make sure the right data will be used in the right way to identify and support trusts who may be vulnerable to bad outcomes.[21] Although the cases involving Lucy Letby obviously significantly differ from those covered in the East Kent Inquiry, they do again serve to highlight concerns about the ability of Trusts to detect patient safety issues in maternity care and promptly respond to them. It also points to problems concerning whether patient safety investigations result in learning and improvement, an issue also highlighted in East Kent.[22] We believe that this should be a key area for the inquiry to explore. The need to improve patient safety investigations has long been acknowledged by NHS England, who are currently rolling out a new Patient Safety Incident Response Framework (PSIRF) aimed at changing this.[23] This framework sets some requirements for incident investigation but provides increased flexibility for Trusts to decide their own criteria for undertaking patient safety incident investigations.[24] How this is implemented and monitored may also be of specific relevance to the inquiry’s investigations, whether the ‘Learning from Deaths’ Guidance is being properly implemented and whether this is sufficient to manage the risk of avoidable harms and death.[25] Failures in leadership and governance A third key patient safety theme that emerges from the Lucy Letby case relates to serious failures at a leadership level in identifying and preventing the serious harm and deaths to babies she was responsible for. Examples of this include: Whistleblowers saying that the hospital could have taken more definitive action at an earlier stage when clinicians were reporting concerns.[26] The former chair of the Trust, Sir Duncan Nichol, stating that Board members were “misled” by hospital executives about the severity of these issues.[27] Concerns that hospital executives placed reputation management over acting on serious safety concerns.[28] [29] The inquiry will need to look in-depth at how these issues specifically manifested themselves at the Countess of Chester Hospital. Again, this is another failing that we commonly see raised in other patient safety inquiries, including last year’s East Kent Maternity Review. In the context of the Lucy Letby verdict, commenting more broadly on how NHS Boards approach patient safety, Sir Stephen Moss, the former turnaround Chair of the Mid Staffordshire NHS Foundation Trust and Patient Safety Learning trustee, has reflected that: “There is a lot of rhetoric that goes on and many chairs and board members tell me that patient safety is obviously their priority. But when I follow that up by asking 'what this means in practice', the response is often disappointing. Boards and leaders need to better understand that their primary role is to provide staff on the frontline with everything they need to do their job well—and the most important part of that role is to keep patients safe.” At Patient Safety Learning we believe that there needs to be a more effective leadership and governance for patient safety in both the NHS and independent sector. There should be high standards and behaviours set for our leaders and they should be supported by specialist patient safety, organisational development and governance experts. We are investing our time and expertise to support organisations in this, and we see effective leadership behaviours and governance as a key issue that needs further exploration by the inquiry. Will anything change? Inquiry findings and implementation In this article we have identified three key patient safety themes that we believe should be considered as part of the inquiry following the Lucy Letby verdict. There has been a succession of major patient safety inquiries over the past twenty years in the UK. However, as identified in our report last year, Mind the implementation gap, far too many of these are followed by promises to learn lessons from the past, but their implementation remains inadequate and patchy and their impact left unmonitored and often unevaluated.[12] It is vital that this mistake is not made again in this case; furthermore, the Government response must ‘join the dots’ between the overarching themes that emerge from this and other inquiries where there is a clear need for action. Good leadership should drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. We identify this as one of the six foundations of safer care in our report, A Blueprint for Action, and as a key part of our organisational Patient Safety Standards.[30] [31] In light of the shocking outcomes of the Lucy Letby case, and the serious shortcomings at a leadership level, we believe NHS England and Trusts cannot simply sit back and wait for this inquiry’s findings and recommendations, which may be years away. Actions need to be taken urgently, informed by the inquiry, of course, but also using the knowledge and evidence from the many tragedies in the past. There needs to be a serious effort by leaders (Executives, Boards, Clinical Leaders, Integrated Care Boards, NHS England and others) to reflect on their organisation’s approach to patient safety and for them to model and deliver high and consistent standards and behaviours, placing patient safety at the core of health and social care. We owe it to everyone who has experienced preventable harm in our healthcare system to not just say ‘patient safety is a priority’ but to act on and be held accountable for delivering this. References BBC News, Nurse Lucy Letby guilty of murdering seven babies on neonatal unit, 18 August 2023. Sky News, Lucy Letby will die in prison after receiving 14 whole-life sentences, 21 August 2023. Department of Health and Social Care, Government orders independent inquiry following Lucy Letby verdict, 18 August 2023. The Telegraph, Judge-led Lucy Letby inquiry ‘would take too long’, 21 August 2023. Health Service Journal, Deaths inquiry thrown into doubt as only 11 staff agree to give evidence, 13 January 2023. UK Parliament, Ministerial Statement – Mental Health In-patient Services: improving Safety, 28 June 2023. The Independent, Lucy Letby inquiry could get statutory powers, No 10 says after pressure from victims’ families, 21 August 2023. BBC News, Lucy Letby inquiry should be led by judge, committee chair says, 21 August 2023. Health Service Journal, Revealed: How trust execs resisted concerns over Letby, 18 August 2023. BBC News, Hospital bosses ignored months of doctors’ warnings about Lucy Letby, 19 August 2023. Patient Safety Learning, Still not safe to speak up: NHS Staff Survey Results 2022, 23 March 2023. Patient Safety Learning, Mind the implementation gap: the persistence of avoidable harm in the NHS, 7 April 2023. NHS England, The NHS Patient Safety Strategy; Safer culture, safer systems, safer patients, July 2019. NHS England, Improving patient safety culture – a practical guide, 11 July 2023. NHS England, Safety culture programme group (SCPG) report: Overview of safety culture discovery and discussions 2021, Last Accessed 22 August 2023. NHS England, Letter: Verdict in the trial of Lucy Letby, 18 August 2023. Patient Safety Learning, The elephant in the room: Patient safety and Integrated Care Systems, 11 July 2023. Department of Health and Social Care, A promise to learn – a commitment to act: improving the safety of patients in England, 6 August 2013. The Sunday Times, Revealed: the files that show how Lucy Letby was treated as a victim, 19 August 2023. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. Department of Health and Social Care, Government response to ‘Reading the signals: maternity and neonatal services in East Kent – the report of the independent investigation’, 3 August 2023. Patient Safety Learning, Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report, 17 November 2022. NHS England, Patient Safety Incident Response Framework, Last Accessed 21 August 2023. NHS England, Patient safety incident investigation, August 2022. NHS England, Implementing the Learning from Deaths framework: key requirements for trust boards, July 2017. The Guardian, Lucy Letby whistleblower says babies would have lived if hospital acted sooner, 18 August 2023. The Guardian, Lucy Letby NHS trust chair says hospital bosses misled the board, 20 August 2023. The Chester Standard, Countess of Chester Hospital under pressure over Lucy Letby, 19 August 2023. Nick Timothy, Too many institutions put their reputations ahead of the public, 20 August 2023. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. Patient Safety Learning, Patient Safety Learning’s Patient Safety Standards, 21 June 2023.

Patient Safety Partners (PSPs) are being recruited by NHS organisations across England as part of NHS England’s Framework for involving patients in patient safety. PSPs can be patients, relatives, carers or other members of the public who want to support and contribute to a healthcare organisation’s governance and management processes for patient safety.  In this blog, Chris Wardley, PSP at a large NHS hospital trust, introduces the Patient Safety Partners Network (PSPN). Chris describes his own experience of starting as a PSP, talks about the large scope of the role and highlights the unique opportunity to influence how an organisation approaches patient safety. He also invites PSPs to join the new network, talking about how it is already helping PSPs in England share learning as they shape their new roles. The Patient Safety Partner role introduced by NHS England is new and aims to take the involvement of patients, families and carers in how healthcare organisations are run to a different level. NHS England states that having a PSP “requires power sharing, a commitment to openness and transparency between staff and patients, as well as good leadership; it must not be tokenistic.”[1] The invitation to apply for the PSP role at our large hospital trust said, “this is a new and evolving role designed to shape the future of patient safety in our Trust and across the UK.” When we applied for the role, neither my fellow PSP nor I appreciated the implications of these bold and grand words. PSPs bring with them a wide range of backgrounds and experience, but most importantly, they are there to offer a patient’s perspective. In our careers, both of us held roles leading innovation for change. My fellow PSP trained as a nurse in the same Trust and was a senior nurse in others before moving into nursing education. I am a chartered engineer and former senior manager in the construction industry. Both of us had also spent several years promoting the patient, family and carer voice in a county-wide role. When we started as PSPs earlier this year, neither of us expected to have any influence for a while. But after a few months, we started to make welcomed prompts and suggestions. Now after six months, this is progressing rather faster, and we are excited that we have a small but important part to play in improving patient safety in our Trust. Why do Patient Safety Partners need a network? Some PSPs are supported by local networks—which might be informal arrangements between local trusts or organised by Integrated Care Boards—but very many aren’t. Organisations are recruiting to these new roles in many ways, seeking a wide range of experiences and expecting very different levels of engagement and influence from the PSPs they engage. The PSPs who are part of the Patient Safety Management Network (PSMN) suggested that an informal, peer support and learning community specifically for PSPs would be valuable. We were therefore delighted that Patient Safety Learning agreed to convene a discussion forum and following this, support a dedicated network. The Patient Safety Partners Network (PSPN) is only a few months old but already has over 70 members. It has held three virtual meetings, focusing on topics of interest to PSPs: communication and variation in PSP roles between trusts. Since we started as PSPs, we have both found the network a great resource for sharing and learning from others both in the same role and outside it. Having the opportunity to connect with PSPs working in different settings gives us the opportunity to hear new perspectives and support each other. At the meetings, we talk about how our role is playing out in real life, what our expectations and issues are, and how we are each getting involved in improving patient safety. It’s a unique opportunity to learn from each other and understand how other organisations are dealing with patient safety issues and big governance changes such as the roll out of the Patient Safety Incident Response Framework (PSIRF). [2] The conversations we’ve had have been very helpful. We’re beginning to understand the variation in roles in terms of how PSPs are engaged, their level of involvement in organisational processes and governance, and what they are being asked to do practically. The network is currently running a survey for PSPs to help establish how they are operating across England. As they become established, PSPs are taking a range of approaches—some are beginning by engaging with patients and front-line staff, while others are finding a place on senior level committees. At our Trust, my fellow PSP and I have focused on using our different experiences and strengths. Wherever you are focusing your time, being a member of the PSPN can help you gain the information and confidence to connect with the people in the engine room of your Trust, where you can have a real influence on making improvements for patients. Commitment The PSPN meets online each month on a Tuesday—we alternate meetings between daytime and early evening to fit the availability of different members. Several of our members take turns to chair the meetings and all PSPs are welcome. Our meetings last an hour, and the discussion is always based around topics raised by members. We would love to hear your views and experience at the meetings, but there is no pressure to contribute if you prefer to just watch and listen. You can also use the chat function in Teams to ask questions and suggest topics during the meeting. Someone takes notes at each meeting so that those who are unable to attend can catch up, but these are only shared on the private PSPN area of the hub, and all comments are non-attributable. The PSP network meetings are safe spaces amongst colleagues. Membership The network is open to Patient Safety Partners working with NHS organisations in England. It is hosted on the Patient Safety Learning hub and you can join by signing up to the hub today. When putting in your details, please tick ‘Patient Safety Partners Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected] to apply to join the PSPN. Other patient safety networks supported by the hub Find out more about the growing number of informal peer support networks hosted and supported by Patient Safety Learning. The networks provide a forum for people involved in patient safety to meet up, share ideas and initiatives and learn from others. Related reading Patient Safety Partners - A workshop at Kingston Hospital Reflections on PSIRF, patient engagement and why we investigate: a recent discussion at the Patient Safety Management Network Top picks: PSIRF insights and opinions Top picks: PSIRF tools, templates and examples References 1 Framework for involving patients in patient safety. NHS England and NHS Improvement, 29 June 2021 2 Patient Safety Incident Response Framework. NHS England, 16 August 2022 3 NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. NHS England and NHS Improvement, 2 July 2019

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jenny talks about the challenge of keeping up with and prioritising new guidance and the need to streamline recommendations to ensure they are implemented efficiently. She also discusses the importance of getting the basics, like staffing levels, right and how sea swimming has influenced how she sees patient safety.

This day will explore what clinical governance means for frontline clinicians. Based on experiential learning techniques, drawing on live case studies and shared experiences of the participants, it looks at the challenges that colleagues working in healthcare settings encounter as part of their journey into patient safety and overall clinical governance and what needs to happen to the system safer for the staff and the patients. Working in partnership, this day draws on expertise from the healthcare leaders and front line clinicians from BAPIO. It is grounded in principles of clinical governance which will be brought to life by the diverse experience and skills of the delivery team. The conference is open to anyone working in a health care setting who is involved in leadership role or providing care to patients. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/reinvigorating-clinical-governance or email [email protected]. hub members receive a 20% discount. Email [email protected] for discount code. Follow on Twitter @HCUK_Clare #ClinGov

This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction from Spring 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email [email protected] Follow on Twitter @HCUK_Clare #NHSSeriousIncidents hub members can receive a 20% discount. Email [email protected] discount code.