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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.

My last blog, "Forgotten heroes" – the sequel, built upon a very moving BBC Panorama programme Forgotten heroes of the Covid front line. The BBC documentary told the sad story of healthcare workers (HCWs) who had bravely and knowingly put themselves in harm's way to care for their patients during the darkest days of the pandemic. Many lost their lives, while many more were rendered so severely injured by the disease (Long Covid) that they were (and remain) unable to work and have been unceremoniously sacked by their NHS Health Trusts/Boards. The way that an organisation manages its activities is known as 'governance'. Good governance will lead to high standards of ethics, morality, care and compassion for the people who work within it and those who may be affected by its acts and omissions. Hence, when applied to a whole country, it is known as 'Government', its departments and agencies. In this blog, I propose a possible hypothetical scenario that may have led to the tragic situation revealed by the BBC documentary. I hope this will lead you to consider the standards of 'governance' that apply to the 'duty of care' which a Government owes to its HCWs during a pandemic and what, morally and ethically, should be done to support those "forgotten heroes" if the Government’s governance should be found to be severely lacking. But is the scenario I am asking you to imagine hypothetical or is it real? I shall leave that to your judgement – and that of the Covid-19 Public Inquiry.  The hypothetical scenario In the wake of the SARS outbreak (Severe Acute Respiratory Syndrome) in 2003, an enlightened Chief Scientific Advisor set a plan in motion to prepare the country for a major pandemic. All epidemiologists worth their salt knew that this was inevitable and would happen one day. Thoughts began to turn towards how HCWs should be protected while caring for infected patients. After all, if large numbers of them became infected then who would look after the rest of us? The health service would most likely be overwhelmed and the country would be thrown into chaos and civil disorder. So a laboratory run by scientists from the country’s foremost health and safety regulatory body undertook some research to discover how well the standard surgical masks (‘medical masks’) would fare in a pandemic. The results were unambiguous – “badly”! The scientists found live viruses behind every surgical mask tested, including fluid resistant surgical masks (FRSMs), when presented with an artificially generated sneeze or cough. The scientists were quite clear in recommending that HCWs should wear respiratory protective equipment (RPE) in order to be properly protected against inhalation of harmful (pathogenic) viruses in the event of a pandemic. There are several types of RPE, the disposable respirator known as FFP3 (filtering facepiece) and some other reusable types as well, which give good protection. Not long afterwards, the 'Swine flu' pandemic raced across the world. This triggered the Government to invest in a massive stockpile of RPE. As the years rolled by, this equipment reached its expiry date but, instead of renewing them, stickers were over the expiry dates extending their life after what were called ‘stringent tests’. One has to question how ‘stringent’, when it is known that some of the materials from which they are made degrade over time and this impairs their efficiency. Tests (even ‘stringent’ ones) can only show how a mask performs at the time of the test and not predict how it will perform in a few years’ time. Manufacturers assign an ‘expiry date’ for a very good reason – when used beyond that date they may fail in such a way that the wearer is unwittingly inhaling the hazardous airborne materials, such as dusts or virus-laden aerosols from which they thought they were being protected. Or, also dangerous, bits of the degrading mask may be inhaled by the wearer presenting a choking hazard. Around that same time. some of the health department’s experts that concluded that SARS coronaviruses were transmitted by droplets and the airborne route via aerosols and tiny particles known as 'droplet nuclei'. They recommended that RPE such as FFP3 respirators should be used when providing routine care to infectious patients. The years passed by and the stockpile came up for review again. Experts from the Government’s health department met to decide what to do. After all, there would be a significant cost to the country in renewing the stockpile, most of which was well out of date. The experts came up with a bright idea –- why not implement a process called 'stock rotation' where PPE would be withdrawn from the stockpile in good time before its expiry date and sent for use in the NHS, replacing it with new PPE. One might question why this simple process wasn't thought of back when the stockpile was first established – after all, it is a fairly commonplace practice in warehousing perishable goods with a shelf-life. This group was fortunate in that it included one of the experts who had authored the above-mentioned paper. Curiously though, they decided that all general ward, community, ambulance and social care staff would only be equipped with FRSMs who they considered need not be protected with proper RPE. Perhaps their attention had wandered away from SARS and were focused on other respiratory diseases like flu (notwithstanding the massive loss of life these caused during the last century). Roll forward a few more years and a SARS pandemic starts to spread out from a place called Wuhan in China with a virus that was 80% similar to its predecessor from 2003, which had been proven to spread by airborne/aerosol transmission.. The new disease was classified as an airborne HCID (high consequence infectious disease) for which the country’s health and safety rules required that HCWs be equipped with RPE (not surgical masks). The Director-General of the World Health Organization (WHO) announces to the world that the disease was airborne (although apparently ‘not in a military sense’ which is a little difficult to understand). A senior medical officer tells a committee of politicians that the disease approaching the country had a very strong force of transmission and is airborne. Then the pandemic arrived in the country, after having wreaked havoc with health services elsewhere in Europe. However, what the pandemic planners did not seem to have taken into account was that the health and safety rules associated with HCIDs required that RPE must be worn by healthcare workers when caring for infectious patients and now the stockpile of respirators was far too low. With not enough respirators to go round, what on earth was to be done? A Government Committee met to consider this dilemma. Two of the experts were present who had authored the paper mentioned above which had explicitly stated that RPE should be worn for SARS coronaviruses, and one of these experts had made the fateful recommendations about the PPE stockpile. This must have all been terribly embarrassing. Anyway they came up with a pragmatic answer to the problem. Solution: Declassify the disease so it isn’t an HCID any more. Done with a phone call to the right person and a quick confirmatory letter back from them. The disease was no longer ‘high consequence’ (just two days after a global pandemic had been declared by the WHO and the worldwide death toll was on a sharp upward trajectory). But oh dear! There is still a problem. Regardless of any HCID rules, the country’s health and safety laws say that if a hazard is airborne then RPE is required (which, as we know, does not include these paper surgical masks). The emergency pandemic legislation brought in by the country’s government had not repealed, revoked or suspended any of the health and safety laws and so they were still in force. This, being 'criminal law' was something that people could be jailed for breaching. Solution: Despite existing evidence that SARS coronaviruses (and other respiratory infectious diseases, such as tuberculosis) are transmissible via the airborne route, the health department pronounces that the virus causing the current pandemic is actually no longer airborne. They say that it is only transmissible via droplets that quickly fall to the ground or onto surfaces. They say that they will only cause infection if they land on someone’s mouth, nose or eyes or a person touches those surfaces and then touches their mouth, nose or eyes. So the country’s response strategy centres around keeping people 2 metres apart and handwashing. The airborne route is largely ignored except for some HCWs who don’t believe them and buy their own RPE – only to be instructed by the hospital authorities to take them off (on pain of disciplinary) and put on surgical masks instead. After all, if they wore these respirators it might scare the patients. But there is yet another problem. When any pathogenic viruses are ‘on the loose’ then the country’s health and safety law says that approved PPE must be worn to protect the wearer if no other, more effective risk control measures can be implemented. For administering close-quarter care to infectious patients no other risk control measures are practical other than PPE. The problem is that surgical masks are not approved 'PPE'. They are designated as ‘medical devices’ which are intended to protect the patient from drops of mucus or saliva that may come out of a HCW’s nose or mouth and may infect the patient. Furthermore the European standard for surgical masks says that they are not intended for protection of the wearer. Solution: We’ll call surgical masks 'PPE' anyway – after all the middle 'P' (protective) has a nice ring to it and should lead HCWs to believe they’re being protected (despite the underlying risk that they may be lulled into a false security and actually become more vulnerable as a result). The health and safety regulator appears somewhat concerned by this turn of events and makes representations to the other Government departments and the NHS that they should refer to RPE (such as FFP3s) as 'respirators' not 'masks' in order to ensure that the distinction is properly understood. However, this is ignored and FFP3s continue to be referred to as 'masks. So you now have 'FFP3 masks' and 'surgical masks'. After all, one mask sounds much the same as another doesn’t it? After all, if you were to refer to one as a 'respirator' (which sounds much better and more efficient) and the other as a 'mask' (which doesn’t) then workers might begin to question why they are not being given the best protection. Furthermore, all politicians, media and just about everyone else in the country started referring to surgical masks as PPE despite the fact that they are not. When concerns are raised with the safety regulator about this, their response is that, whilst they agree surgical masks are not PPE, the term PPE has now entered common parlance and it would be difficult, if not impossible, to reverse this. And so the myth that surgical masks are personal protective equipment persists to this day. A few days after the ‘downgrade’ from RPE to surgical masks, with the first wave now really taking hold, a doctor in Accident and Emergency at one hospital describes their situation to a politician as carnage and chaos. They were distraught as they didn’t have any proper PPE and needed FFP3s. The doctor felt as though they were being thrown to the wolves. They thought it likely that some of them were going to die as a result. Of course, sadly, that doctor was not wrong. Many did die. Many, many more became very ill with very serious and long-lasting health effects. But where, one might ask, is that regulatory body that is supposed to ensure that workers are kept healthy, safe and properly protected against the hazards they’re working with? Well, they say that decisions about respirators and masks in healthcare sector have nothing whatsoever to do with them. They say that it is the country’s health department and the public health people who issue the guidance about mask-wearing in the healthcare sector. It is they who are responsible for these decisions. Then another problem arises. Oh dear, don't health and safety laws just keep getting in the way when you’re trying to manage a pandemic! For instance, there’s one which says that when a worker contracts a serious disease through their work (or dies of it), then it must be reported to that health and safety regulator as 'occupational exposure'. However, it wouldn’t be good for morale amongst healthcare workers if the true impact the disease was having upon them became widely known. Neither would it be good for those people in the health department who had been responsible (and accountable) for decisions they made about the stockpile the instruction they had given to downgrade from respirators to surgical masks. Solution: Discourage such reporting – ideally stop it altogether! Perhaps, when employers do make such reports, the safety regulator should reject them on the grounds that the healthcare workers probably didn’t catch their disease from the infectious patients they were working with (coughing their germs into the air around them) but more likely ‘out in the community’. So these unfortunate healthcare workers have no official record made of their 'occupational exposure' to the disease and any such suggestion is vigorously denied by their employers. This has the potential to severely hamper those workers when, after a year of sick pay, they are unceremoniously sacked and may need evidence that their disablement was caused through their work. Well, that brings us to the end of our hypothetical scenario. What do you think? Truth or fiction? Related reading: Since the publication of this blog, A Byline Times' investigative journalist has delved deeper into the story and his findings, published here, provide more detail.

This book sets out what the terms governance and leadership mean, and how thinking about them has developed over time. Using real-world examples, the authors analyse research evidence on the influence of governance and leadership on quality and safety in healthcare at different levels in the health system: macro level (what national health systems do), meso level (what organisations do) and micro level (what teams and individuals do). The authors describe behaviours that may help boards focus on improving quality and show how different leadership approaches may contribute to delivering major system change.

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.