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Ambulance services play a pivotal role in ensuring the safety of mothers and their newborns during urgent and emergency situations. These services act as the frontline responders, providing immediate care and facilitating timely transport to appropriate healthcare facilities. World Patient Safety Day, observed annually on 17 September, serves as a global platform to raise awareness about patient safety and encourage collaborative efforts to reduce harm in healthcare settings. The theme for 2025, 'Safe care for every newborn and every child', underscores the critical importance of safeguarding our youngest and most vulnerable patients from preventable harm. In the UK, ambulance services play a pivotal role in ensuring the safety of mothers and their newborns during urgent and emergency situations. These services act as the frontline responders, providing immediate care and facilitating timely transport to appropriate healthcare facilities. Their contributions are multifaceted, encompassing emergency childbirth assistance, neonatal transfers and the management of obstetric emergencies. In addition, many women and families will use the 999/111 service throughout the childbearing continuum, often using these services as a gateway to accessing maternity care. A recent review of Maternity and Newborn Safety Investigations (MNSI) highlighted that 6 in 10 independent investigations that met the criteria for MNSI involved the ambulance service. Out-of-hospital births, though relatively rare, present unique challenges for ambulance clinicians. Intrapartum care accounts for approximately 0.05% of emergency medical services' caseload, with only about 10% of these cases resulting in deliveries managed by ambulance staff. This limited exposure can lead to a decline in obstetric clinical skills, potentially impacting patient care. To address this, continuous training and simulation exercises are essential. For instance, the London Ambulance Service has developed a bespoke communication tool to support midwives in out-of-hospital settings, ensuring effective communication during the transfer of women or babies in emergencies and delivers bespoke mandated emergency training to its frontline clinicians. Such initiatives enhance the preparedness of ambulance clinicians to manage emergency deliveries safely; however, these are not standardised across services. Challenges and areas for improvement Despite their critical role, UK ambulance services face challenges that can impact maternal and neonatal safety. Incidents of delayed response times have been reported, leading to tragic outcomes. For example, a three-day-old baby named Wyllow-Raine Swinburn passed away after an eight-minute delay in answering a 999 call and a 31-minute wait for the ambulance to arrive. Although the delays were not deemed the direct cause of death, they highlighted inefficiencies in the emergency response system. In other cases, the lack of effective training for ambulance clinicians impacted upon the management of a time critical breech delivery, with tragic consequences. Such cases underscore the need for systemic improvements, including better resource allocation, enhanced training and the implementation of robust protocols to minimise delays in emergency response. Collaboration between ambulance services and midwifery teams is essential for improving outcomes in maternal and neonatal emergencies. The development of communication tools and training programmes exemplifies efforts to standardise information exchange during emergencies, thereby reducing the potential for errors and delays. Furthermore, ambulance services are increasingly recognising the importance of specialised roles focused on maternity care. For instance, paramedics with additional training in neonatal and maternity care can provide more comprehensive support during emergencies. Susie, a paramedic with the Northwest Ambulance Service, highlighted her passion for improving maternity care within the ambulance service, emphasising the importance of continuous professional development in this area. Conclusion As we observe World Patient Safety Day 2025, it is imperative to acknowledge and support the vital role of UK ambulance services in safeguarding mothers and their newborns during and following pregnancy. Continuous training, effective communication tools and collaborative practices are essential to enhance the safety and quality of care provided. By addressing existing challenges and building on successful initiatives, we can move closer to the goal of ensuring safe care for every newborn and every child from the very start. Further reading Exploring the pre-hospital setting for the emergency care and transfer of neonates: the role of UK ambulance and neonatal transport services Displaced risk. Keeping mothers and babies safe: a UK ambulance service lens An exploration of maternity and newborn exposure, training and education among staff working within NWAS Disparities In Access to the Northwest Ambulance Service during pregnancy, birth and postpartum period and its association with neonatal and maternal outcomes World Patient Safety Day 2025

This blog provides an overview of a Patient Safety Partners Network meeting on the 4 February 2024. At this meeting, members of the Network were joined by Professor Henrietta Hughes, Patient Safety Commissioner for England. The Network includes Patient Safety Partners, in both paid and voluntary roles within NHS organisations, whose role is to improve patient safety. Patient Safety Learning provides a monthly drop-in session, sometimes with guests, to talk through topical and relevant issues. This facilitates information sharing, peer support and safe space for discussion. The role of Patient Safety Commissioner for England was created by the UK Government after a recommendation from the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Julia Cumberlege. This Review examined the response of the healthcare system in England to the harmful side effects of three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. It described the healthcare system as being “disjointed, siloed, unresponsive and defensive” and found that it did not “adequately recognise that patients are its raison d’etre”. The Patient Safety Commissioner acts as a champion for patients, leading a drive to improve the safety of medicines and medical devices. Role and work of the Patient Safety Commissioner Opening the meeting, the Patient Safety Commissioner, Professor Henrietta Hughes, outlined the background to her post, reflecting that since her appointment in 2022: She has worked with two governments, a wide variety of different NHS organisations and national healthcare bodies such as the Care Quality Commission, NHS England and the Health Services Safety Investigations Body. There has been significant changes made to improve information provided to women of childbearing potential taking teratogenic medications (which carry risks if taken during pregnancy). The roll-out of Martha’s Rule has proceeded at pace across 143 pilot sites in the NHS. Henrietta spoke about the importance of improving how patients are listened to by the healthcare system and the need to place the patient voice at the heart of decision making. Working towards this, she noted that her strategy includes a focus on advocate for partnerships which embed patient safety and patient voice through the healthcare system. Her strategy identifies the roll out of Patient Safety Partners across England as a key element of this. She also spoke about her launch of seven Patient Safety Principles, published last year following a public consultation. She talked about her optimism of seeing these put into use to support planning and collaborative working with patients as partners throughout the healthcare system. She welcomed the opportunity to meet Patient Safety Partners and praised the Network and the work it does to engage, support and inform. Network discussion Subsequently the meeting opened out into a question and answer session which touched on the following areas. Support and impact There was a discussion about what more can be done to maximise the impact of Patient Safety Partners and improve the level of support they receive from the NHS. Henrietta spoke about the parallels between this and the time it took to embed Freedom to Speak Up Guardian roles in the health service. She was previously National Guardian. She also reflected positively on how new NHS planning guidance could support this, with its emphasis on patient experience. Role clarity There was a conversation about how the role of Patient Safety Partners in organisations can be strengthened. It was noted that existing guidance does not specify in significant detail how these roles should work, which can lead to a lack of clarity for Patient Safety Partners. Henrietta reflected on the need to ensure that what is said about ambitions for patient involvement and patient voice at a Board level is also reflected in the practical actions that trusts undertake. Training Henrietta shared her views on how Patient Safety Partners could potentially utilise the Network both to support and learn from each other. She noted the value of being able to understand what training is being provided at different trusts, which Patient Safety Partners could then use to return with new thoughts and ideas to their own organisations. She also pointed to her Patient Safety Principles as a framework for establishing where there may be gaps in what their organisations currently do. Retaining knowledge There was a discussion about how Patient Safety Partners can build on and share their experience once their terms come to an end. This included considering how they might use this in other roles in the NHS, such as governors and non-executive director roles, and the importance of ensuring knowledge and experience is shared with new incoming Patient Safety Partners. Implementation of Martha’s Rule Henrietta highlighted the progress made to date in implementing Martha’s Rule in the NHS. She noted that while it is currently early days, initial data showed that it was already supporting clinical reviews leading to changes in care and safety improvements. She emphasised that this showed the wider value of including patients as part of the healthcare team. Concluding thoughts Hopes and aspirations for the Government’s forthcoming Ten Year Health Plan was also a topic of discussion. Henrietta reflected on the need for the voice of patients to be a core part of this. She is continuously advocating for this in her engagement with Ministers and the leaders of national organisations and regulators. Closing the session, she said that she thought the Patient Safety Partner Network was fantastic and she was pleased that so many people regularly joined these meetings to share valuable insights and experiences. How to join the Patient Safety Partners Network The Patient Safety Partners Network meets monthly in a virtual capacity and now includes more than 160 Patient Safety Partners. These meetings provide a supportive and safe space for Patient Safety Partners to: discuss barriers and opportunities share successes discuss how they can use their collective voice to make a difference for patient safety. Only Patient Safety Partners working within NHS organisations in England can join, although experts are often invited to present or discuss specific topics. If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here. If you would like to attend a Patient Safety Partners Network meeting as a guest speaker, please contact us at [email protected]. Related reading Patient Safety Partners: a toolkit of resources – this webpage brings together a range of different resources designed to share insights and information about the Patient Safety Partner role.

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 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. 'Safety cases' in the NHS – the example of hospital capacity: A blog by Norman MacLeod East London NHS Foundation Trust: World Patient Safety Day – Improving diagnosis for patient safety (16 September 2024)Post 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 blog, author, consultant and patient safety expert Tom Bell shares his story of being approached by an NHS Trust to take up a role as a Patient Safety Partner. He describes how his initial enthusiasm to make a difference was crushed by the Trust’s failure to value his experience and time. Tom describes the Trust’s approach to working with Patient Safety Partners and implementing PSIRF as tokenistic and disjointed. He highlights the gap between the Trust’s stated view about the importance of working with Patient Safety Partners and its disorganised internal systems and unwillingness to manage and compensate Patient Safety Partners for their work. In the summer of 2022, I was approached by the NHS Leadership Academy to see if I would be willing to make myself available to become a Patient Safety Partner for an NHS Trust that might be seeking one. Shortly thereafter I was asked and encouraged by an NHS Foundation Trust to become one of two Patient Safety Partners they wanted to appoint. My lived experience, former NHS management role, and knowledge of delivering healthcare services in rural areas were deemed useful. My role as a Patient Safety Partner started in early autumn 2022. From the beginning I was open in sharing my concerns that not every NHS leader is comfortable hearing what they don’t want to hear. I explained I would not be offended if the Trust felt I was not right for them. I was assured by the Assistant Director for Safety and Quality that my ability to present an alternative perspective would be welcomed. I was delighted. I accepted that the pay was menial in relation to my experience and qualifications, but the improving of patient safety matters deeply to me, as many will know from working with me or hearing me speak at the Annual Patient Safety Congress. Having lost a sister to suicide after a period of sexual abuse and cover up in an NHS mental health hospital and then losing my job as a middle manager in the NHS after whistleblowing in an unrelated incident over two decades later, I have been on a journey I would not wish on others. I understand to the very depths of my gut the need for significant culture change in the NHS in a way few could ever comprehend. I think the Patient Safety Incident Response Framework (PSIRF) is a genuinely well-intentioned initiative. The principles it embodies and the cultural shift it seeks to be the lever for, are massively important. The role of the Patient Safety Partner as outlined by NHS England in helping NHS Trusts successfully and meaningfully implement PSIRF, in form and spirit, is quite rightly held aloft as a significant one. For those like me who are fortunate enough to recover from the rage injustice flushes through our veins and make it through the red mists of righteous anger, the truths our experiences reveal are gifts. The hard-earned insights and knowledge we inadvertently find ourselves possessing, are precious and valuable to those willing to hear and hold them with us. I am continually emerging, if never fully, from my journey with a far greater understanding of the many forces that drive and shape individual and organisational behaviour than my academic qualifications and professional experiences could ever give me. And I remain one of the NHS’s greatest supporters. I understand very few people are inherently bad, whatever that may mean, but I also remain acutely aware that many good NHS employees at every level, feel they are working within sub-optimal systems. As W Edwards Deming rightly observed, “The origin of issues can be largely traced back to the system, not blamed on the people within them.” It will come as no surprise to those who know me that I launched myself proactively into my role as a Patient Safety Partner. I endeavoured to be a well-informed asset to a Trust I thought had placed faith in me. I carried out research and spent a great deal of my own time looking at relevant issues and exploring areas of interest that would add value to my role. Yet instead of the Trust valuing my expertise and input or welcoming the views and information I brought to the table, as well as the positive informed challenge I offered, I found myself being treated incredibly shoddily. Despite being told the work I was involved with was important, more than half the scheduled PSIRF meetings planned for the coming year were cancelled, often at short notice. Those meetings that were held were far too short to accommodate the number of agenda items included in them. Meaty and complex topics such as organisational culture, that required in-depth discussion in their own right, were given minor billing on agendas and skipped briskly over in a matter of minutes. The hour-long meetings that did go ahead were held during staff lunchtimes at which many people were distracted, eating while checking emails. The meetings were classically hierarchically dominated by a director. The majority of attendees offered little if any input. Some of those present never spoke other than to introduce themselves at the first meeting. There was no space or appetite for discussion during meetings. Progress and actions were presented through the usual RAG rating lenses of red, amber or green. I recall during one meeting I asked about progress on a particular issue, to which the chair of the meeting replied that, “Oodles of work has been done in that area.” They seemed surprised when I asked what “oodles” looked like in practice. I was greeted with a confused silence. I explained politely that were anyone to create a report for a regulator or their colleagues stating that “oodles of work had been done,” they might not be taken seriously. My point was acknowledged, I was promised evidence of the “oodles” and the meeting moved on. Of course, I never received what I had been promised during the meeting, despite my follow up emails asking for it. What I find fascinating is that nobody else in the meeting appeared to understand or support my challenge. Why did none of the well-paid presumably well-qualified NHS managers and directors in the room say anything or question the unevidenced assertion their colleague had made? The irony is that I was by many degrees the least well-paid person in the room. To me it seemed the Trust was viewing PSIRF as just another top-down, flavour of the month, centrally-mandated initiative that they needed to demonstrate they were taking seriously by ticking all the right boxes. As anyone with a degree of public sector experience knows, demonstrating you are doing something well is very different to actually doing something well. In my view and based on my experience, the Trust and its directors were simply not making the time to talk about and implement PSIRF meaningfully. As Forrest Gump might say, important is as important does. As the meetings were frequently cancelled and opportunities for face-to-face (albeit virtual) conversation became more limited, I found myself trying to communicate via emails and phone calls. However, trying to get to speak to people on the phone was a nightmare and over three quarters of the emails (yes, I’ve done the maths) that I sent in relation to my role went unanswered. Worryingly, after many months I had not received most of the reimbursement I was owed. I was being bounced around between the NHS Leadership Academy’s and the Trust’s confused and unresponsive admin departments. My requests for an update in relation to the growing amount I was owed, were ignored. I became so frustrated at the lack of responsiveness that I emailed the Trust’s senior leadership team, at which point the Trust actively blocked my email address to stop me contacting them. My access to the Trust was only reinstated when I bypassed the block using another email address and copied in numerous local MPs with whom I shared my concerns. Some of the amounts I was owed related to activity undertaken over nine months previously. I was appalled that an NHS Trust that had approached me for help and assured me my work was important and my input would be valued, was treating me so poorly. It was not the amounts in question that mattered, the reimbursement was essentially tokenistic. It was the principle. Trying to correspond and deal with the administrative mess the Trust was creating was getting me nowhere. The Trust’s own admin and finance teams acknowledged to me that the situation was “shambolic.” I eventually contacted the Trust’s newly appointed Chief Executive, and then when nothing happened, I approached NHS England and the Secretary of State for Health and Social Care. Only after I had done this was I eventually contacted by the Trust to finalise and arrange payment of what I was owed. I should never have had to make such waves to be reimbursed for work I was doing at what ultimately amounted to less than the minimum wage. The Trust published its PSIRF plan and policy in December 2023, at a time when I was in theory still one of its Patient Safety Partners. Despite the many ideas, suggestions, documents and references to useful information I had shared, the Trust did not even let me know they were going to be published. The input I had offered was not used. Early in 2024, the Trust informed me that my services were no longer required, saying they had realised they weren’t yet ready to work with Patient Safety Partners. A classic and deeply ironic cop-out if ever there was one, as well as a shirking of their legislative obligations. I was incredibly disappointed at how I was treated. Those who know me know I do not walk away lightly from any challenge. The concern I am left with is that if the Trust I tried to help is this tick-box-entrenched and administratively shambolic and unresponsive in how it treats its Patient Safety Partners, where else is dysfunctionality occurring in that Trust and the wider NHS? I worry that the involvement of Patient Safety Partners in the creation of many PSIRF related plans and policies has been little more than a tick-box exercise. Having raised my concerns with NHS England, in May 2024 I received a reply. The letter negates any concerns raised using the kind of classic public sector assertion highlighted most recently by the Post Office Scandal. It opens with the statement, “Your experience and the issues you raised are not what we have heard from other Patient Safety Partners…” (nobody else has a problem with their computer system Mr Bates), a statement which I presume has oodles of evidence to support it. As for me, all I know for a fact is that while some Patient Safety Partners are satisfied, others feel undervalued and underutilised. But what would I know, I’ve only spoken to them… This is just one Patient Safety Partner's experience but we have also heard many positive experiences too where Patient Safety Partners are able to make an impact. Further reading: How do Patient Safety Partners feel about their role? Analysis of online survey results Patient Safety Partners: examples of impact Patient Safety Partners: influencing for safety Developing the Patient Safety Partner role: Imperial College Healthcare NHS Trust share their approach Patient Safety Spotlight Interview with Mark Smith, National Patient Safety Partner and South West Yorkshire Partnership Foundation Trust Patient Safety Partner Patient Safety Partners – lack of role clarity a barrier for impact We would love to hear your experiences of being a Patient Safety Partner, please add to the comments below (you will need to be a member of the hub and logged in). If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here.

Embedding the Patient Safety Partner role has been approached differently by different Trusts and organisations. In this presentation, Patient Safety Engagement Manager, Lea Tiernan talks about how they have worked hard to  develop the role at Imperial College Healthcare NHS Trust in a meaningful and strategic way. Lea is joined by Armine Afrikian, a Patient Safety Partner to explain more about: their five Patient Safety Partners how they have developed the role workstreams highlights challenges the Patient Safety Engagement Manager role. Join the Patient Safety Partners Network In June 2023, Patient Safety Learning established the Patient Safety Partners Network. The network meets monthly in a virtual capacity and now include more than 150 Patient Safety Partners. These meetings provide a supportive and safe space to: discuss the barriers and opportunities share successes discuss how they can use their collective voice to make a difference for patient safety. Only Patient Safety Partners working with NHS organisations in England can join, although experts are often invited to present or discuss specific topics. If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here. If you would like to attend a Patient Safety Partners Network meeting as a guest speaker, please contact us at [email protected]. Related reading Patient Safety Partners: examples of impact: Speaking to members of the Patient Safety Partners Network, as well as a manager of five Patient Safety Partners, we hear how their work is having a positive influence on patient safety. The voice of the patient safety frontline: Chris Wardley, Patient Safety Partner at a large NHS hospital trust, introduces the Patient Safety Partners Network (PSPN). Patient Safety Partners – lack of role clarity a barrier for impact: this shares 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 PSPs to have a positive impact for patient safety, as intended. Patient Safety Partners: recruitment and induction: the 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: this includes some suggested approaches and actions that Patient Safety Partners and trusts might take to help the role have greater influence and impact. 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.

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 the National Patient Safety Strategy. In this blog, we explore some early examples of the impact the Patient Safety Partner role is having. Speaking to members of the Patient Safety Partners Network, as well as a manager of five Patient Safety Partners, we hear how their work is having a positive influence on patient safety. Highlights from Suffolk and North East Essex Integrated Care Board Michelle Grimes is a Patient Safety Partner at Suffolk and North East Essex Integrated Care Board. She's been involved in several safety projects where she's been able to have direct impact. Michelle has drawn out four key projects she has been involved in as part of her role as a Patient Safety Partner. Developing information leaflets for patients and staff I have helped produce two important information leaflets, where a gap was identified. The first was to help primary care staff understand the shift to 'The Learn from Patient Safety Events' (LFPSE) approach and encourage their transition to it. This went to all of primary care, including community pharmacies who historically tend to have low levels of reporting incidents. Some reports have begun to come in from pharmacies using the new system, which is brilliant. The second was a patient information leaflet relating to harm caused by sodium valproate, signposting people to sources of support. It was collated in response to a pharmacist asking at our medication safety collaborative where she could direct patients. Adapting the duty of candour letter I have been integral to collaborative work to adapt the duty of candour letter. We have changed it to reflect a systems approach following patient safety incidents that have happened whilst in the care of more than one organisation. Helping families raise concerns I have also been involved in the implementation of a service for families and carers. ‘Call 4 Concern’ helps people request further clinical opinion if they feel their relative is deteriorating and it isn't being recognised, or they feel their concerns are not being heard. Raising awareness of the role On World Patient Safety Day last year we presented an outline of the Patient Safety Partner role and how we hoped to develop it to an audience of various health professionals, service users and third sector staff. The feedback was that people felt it was positive to have patient/carers/relatives’ views represented in this new role, and they looked forward to seeing it develop. Improving ventilation standards at United Lincolnshire Hospitals NHS Trust Elaine Freeman is a Patient Safety Partner at United Lincolnshire Hospitals NHS Trust. Below, she describes how she helped improve standards of ventilation in treatment rooms across the 1000-bed Trust. Our Trust implemented the Patient Safety Partner role in September 2022, and we were all given a portfolio to manage. Due to my nursing background, I was given a clinical portfolio. This included attending the Infection Prevention and Control Group. It was through this group that I became very concerned about a ventilation report, particularly regarding treatment rooms. After various conversations, some research into ventilation guidance, and raising my concerns at committee meetings, I became part of a small working group led by two wonderful senior nurses. Our focus was to gather evidence that would drive change and improvement. Our first report identified rooms unfit for purpose, due to poor air exchange etc. Since then, a great deal of change has taken place for example: some rooms have been downgraded in relation to what procedures can take place the swapping of rooms to ensure good air exchanges improvement of air changes to some rooms by the estates engineers ensuring that the treatment rooms are not also used as a store room no cloth covered furniture or poorly fitted blinds that cannot be cleaned no mobile ventilation units hanging out of a window. Further insights from Patient Safety Partners In addition to Michelle and Elaine’s examples, Patient Safety Partners have been sharing further feedback on the early impact they are having in their roles: “One of the things that I have recently been involved in as a Patient Safety Partner is working with the Falls Group as an actor in a series of videos to highlight potential falls risks. The videos are currently being finalised, but it has allowed me to have an input into how falls might be reduced.” Colin Fiske, Patient Safety Partner at United Lincolnshire Hospitals NHS Trust. “An older lady was brought into the emergency department and unfortunately died. Due to the number of patients in the emergency department there were two patients to each resus bay. So when this lady came in and staff were attempting to save her life there was another patient in the bay who unfortunately witnessed all of this. There was a full Patient Safety Incident Investigation report on this and the report indicated that the staff involved had received support, but there was no mention of any support being provided to the other patient. As a result of me raising this, the patient has now been given all the relevant support.” Patient Safety Partner. Designing a strategy with Patient Safety Partners In a recent interview for the hub, Patient Safety Engagement Manager, Lea Tiernan explained how the five Patient Safety Partners in her team were integral to developing their initial strategy: “Early in their tenure, the Patient Safety Partners and I met fortnightly to design our initial strategy for involving patients in patient safety. We used the model for improvement to approach this, and after generating a driver diagram, we broke the work down into five workstreams. These include: Patient Safety Partner programme. Community engagement. Staff engagement and training. Learning response engagement. Equity and inclusion. The Patient Safety Partners expressed an interest in the workstreams, and we have at least two partnered with each.” Share your experience as a Patient Safety Partner It's great so see the impact Patient Safety Partners are already having. We'd love to collate more examples. If you are a Patient Safety Partner and would like to share how you are making a difference (big or small), to inform and inspire others, please contact our editorial team at [email protected]. Join the Patient Safety Partners Network In June 2023, Patient Safety Learning established the Patient Safety Partners Network. The network meets monthly in a virtual capacity and now include more than 150 Patient Safety Partners. These meetings provide a supportive and safe space to: discuss the barriers and opportunities share successes discuss how they can use their collective voice to make a difference for patient safety. Only Patient Safety Partners working with NHS organisations in England can join, although experts are often invited to present or discuss specific topics. If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here. If you would like to attend a Patient Safety Partners Network meeting as a guest speaker, please contact us at [email protected]. Related reading The voice of the patient safety frontline: Chris Wardley, Patient Safety Partner at a large NHS hospital trust, introduces the Patient Safety Partners Network (PSPN). Patient Safety Partners – lack of role clarity a barrier for impact: this shares 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 PSPs to have a positive impact for patient safety, as intended. Patient Safety Partners: recruitment and induction: the 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: this includes some suggested approaches and actions that Patient Safety Partners and trusts might take to help the role have greater influence and impact. 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.

This conference focuses on patient involvement and partnership for patient safety including implementing the National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework. https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-involvement or email [email protected] Follow this conference on X @HCUK_Clare #PatientPSP2024 hub members receive a 20% discount. Email [email protected] for discount code.

Melanie Whitfield, Associate Director of Patient Safety at Kingston NHS Foundation Trust, and Helen Hughes, Chief Executive of Patient Safety Learning, recently ran a workshop for Patient Safety Partners (PSPs) at the Kingston Trust. Here is a summary of the workshop. PSPs are vital in bridging the gap between healthcare providers in the UK and the patients who use these services. They are the patient’s voice and enable us, as providers, to ensure we are putting our patients first, challenging us when things go wrong and asking the difficult questions. But what is their role and why are they so important? In July 2019, the NHS Patient Safety Strategy was released with a framework for PSP involvement in healthcare organisational safety. This relates to the role that patients, carers and other lay people can play in supporting and contributing to a healthcare organisations’ governance and management processes for enhancing and improving patient safety. This is a voluntary role with the official allocated time given to PSPs to complete their work at Kingston being 1.5 days per month. The role for PSP’s was outlined as follows: Membership of safety and quality committees whose responsibilities include the review and analysis of safety data. Involvement in patient safety improvement projects. Working with organisation boards to consider how to improve safety. Involvement in staff patient safety training. Participation of investigation oversight groups. We know that the opportunity and benefit of PSPs is so much more than this. So Melanie and Helen developed the idea of a workshop for PSPs, the patient safety team, the staff wellbeing chaplain and PEPI lead to share experiences of the first year of PSPs, to learn from each other from this experience, celebrate achievements and impact, and to discuss opportunities to promote listening and learning from patients to shape the future journey. Helen facilitated the workshop and the discussions and outcomes of this are outlined below. The session started with what do we want from PSPs. Reflections included: Take us out of our comfort zone; challenge us on our actions and evidence and ‘bring us back to reality’ of what it’s like to be a patient or family member. Help us look at systems and culture and for PSPs to ask difficult/challenging questions – ‘lift the rocks and see what’s underneath’. Remind us that following up when things go wrong isn’t just about incident reviews and report writing, there are patients involved. Help us close the gap between patients and staff and build the interaction between patients, staff and patient and staff safety. Bridging the gap between patients and clinicians responsible for them. Leadership and insight by doing together. Patient safety improvement and prevention by providing information to patients sooner. Improving communication by being more visible. Raising PSP profile for staff and patients. Access to networks within the community. Real time listening rather than delayed Duty of Candour. Usefulness of speaking up and the consequences of not wanting to. Everyone agreed this is a huge and challenging agenda but it’s what’s needed. There was huge energy in the room and motivation to work collaboratively to address these issues. During the workshop Three of the PSPs were then asked for an insight into their role, what they want to achieve from the role and what barriers they face. This was a rich session with much insight, including these issues highlighted by PSP colleagues: We’re all passionate about patient’s voice being heard; what can we do to help the NHS and give back. There’s a real desire to fix things and it make better and to implement ideas that can be easily rolled out. It’s still an evolving role – by the time we’ve got the skills and knowledge to do a good job our time in the role may be at an end, so we need to create longevity in the role, including succession planning. There are huge amounts of learning to be done. Opportunity to be more effective by being project based and utilising volunteers. Feeling really welcomed and accepted; feeling lucky to be a part of the team. The value of PSPs being outside ‘experts’ who may have access to other networks, e.g. in voluntary sector, children’s services How do we best use PSP individual experience and knowledge? Awareness of staff pressures. There’s a huge opportunity for PSPs but do we have sufficient numbers and time? Opportunity to demonstrate value and create the business case for more resourcing. Meetings are often fast paced meetings with no time to ask questions; if decisions are already made, what’s the value that PSPs can bring? And it’s a real struggle to understand NHS terminology and jargon. There is a need for improved visibility of PSPs, with staff and patients; comms and engagement strategies needed. Demonstrate the credibility of the role. Difficulties of families having their voice heard. How can patients be signposted, what are the communication pathways? “I’ve attended meetings where Trust colleagues didn’t understand who we were or what our role entailed. We need clear guidance on our job description and need better visibility to Trust colleagues, so they know who we are. I would love for us to be involved in policy writing and attend formative discussions on major transformation project with high impact on patient safety.” Michelle Deans – Hounslow and Richmond Community Healthcare. “Patients need to have their voices heard; therefore, a clear communication pathway is essential. The language used by clinicians in incident reports is far too complex for the average reader to understand and often implies negative connotations. We need to be fully visible for both staff and patients, but we only have so much time.” Sue Strudwick – Kingston Hospital Foundation Trust. “I’ve struggled with understanding NHS terminology having had no clinical or NHS experience in my life. The meetings we are asked to attend can often be fast paced with no time to ask questions. I would love this role to be more project based utilising hospital volunteers.” Chloe Scott – Hounslow and Richmond Community Healthcare. As you can see, the PSPs have challenges within their roles which is no doubt reflected across the country. The workshop provided an opportunity for the PSPs and staff to come up with ways to work together to improve patient safety. Everyone agreed the biggest opportunities would come from visibility, education and direct engagement with patients. Here are some of the ideas that came up: Use of social media channels to publicise the role of the PSP at the Trust, including visibility on our internet and intranet page. Frontline patient engagement, including ward walkabouts, pop-up desks and drop-in sessions. PSPs to hold us to account when things have gone wrong ensuring constructive follow up on action plans and improvements. Spreading the word through patient stories and experiences. PSPs to have regular interaction/involvement with quality improvement to influence what projects are completed and how the patients are involved. Collaborative/cross organisational working. More thinking is needed on how we recruit PSPs that reflect the diversity of the community we serve. Involvement in the new Patient Safety Incident Response Framework (PSIRF) and patient safety incident investigations (PSIIs). It is important we highlight to the staff and patients that patients and families need to be able to speak to the right people in real time. We don’t want something to go wrong and then people pick up on it afterwards; we want to encourage staff and patients to speak up when they have questions that need answering and to be able to be listened to when they recognise that something is about to go wrong. We know we can’t stop things from going wrong, but prevention and learning from incidents is well within our control. With the help of our PSPs and educating patients and staff, we can make the necessary improvements to ensure our patient’s safety is always our priority. We hope that by sharing this blog with colleagues in the NHS in England, others can learn from the ambition, excitement and opportunity at Kingston for the PSP role. As we develop, we’re keen to share our journey and collaborate with colleagues, through the newly established Patient Safety Partnership Network and with Dr Henrietta Hughes, the Patient Safety Commissioner.

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

In this interview, we talk to 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. She shares her personal learning along the way and ends by offering advice to anyone else seeking to embed the Patient Safety Partner role within their organisation.  Can you tell us a bit about yourself? My name is Lea Tiernan, and I have worked at Imperial College Healthcare NHS Trust since 2018. I am responsible for leading the development and implementation of our Trust’s strategy to involve patients in patient safety. I have a background in quality improvement (QI), which has been invaluable when designing this programme of work alongside our Patient Safety Partners, local community and staff. How did you go about planning and preparing for the Patient Safety Partner role? We have been fortunate that at the Trust our senior leadership were bought into the idea of the Patient Safety Partner role early on. They supported its implementation and created a Patient Safety Partner policy, prepared for an inclusive recruitment process and planned for a thorough induction once they came into post. Their induction included a pack providing key information, attendance at our corporate induction session, meeting key colleagues and codesigning an agreement for how we would work together. Our senior leadership team quickly realised that we needed more resources to manage the Patient Safety Partners in a meaningful way and meet the ambitions of the framework to involve patients in patient safety. The Patient Safety Engagement Manager role was conceived, and I was recruited into the role in February 2023. How did you approach the recruitment stage? Our Trust Medical Director’s office was responsible for the recruitment process and were supported by the Recruitment Team. We set out with the aim of having a group of Patient Safety Partners that were as diverse as our community, so we knew we needed to actively promote and support applications from all parts of our local area. This meant that whilst we advertised the role through regular channels like our website and NHS jobs, we also worked with our internal Involvement Team to share more widely. This included promoting the role through: social media channels the Black and Minority Ethnic health forum charity volunteer contacts Nextdoor website local Healthwatch local authorities maternity voices group other community contacts. Once we opened to applications, we continued to follow an inclusive recruitment approach to avoid limiting applications, for example offering informal discussions during the process. Can you tell us about the Patient Safety Partners that you have in post? We have five Patient Safety Partners, and their day-to-day lives all look very different. We have a mix of professionals working in accounting, community leadership and other patient partnership roles. We also have two Patient Safety Partners that are students, one in law and one in medicine. Their skills and experience with the NHS are varied too. Some Patient Safety Partners have extensive experience as patients, and bring this to the role. Whereas others are focused on how they can make healthcare safer for their local community by looking at language and cultural barriers. Our Patient Safety Partners also represent a wide range of ethnic backgrounds and ages, which greatly adds to cognitive diversity, especially when carrying out group work. It means that we have a broad agenda, and our Patient Safety Partners are great at taking a strategic view to how we deliver our work. A shared love of food has been a great way to bond as a group and when we meet in person, Patient Safety Partners bring their favourite snacks. When the Patient Safety Partners were still new to the Trust, I would often run ‘icebreakers’ in our meetings to learn more about them and help the group gel. At the start of one meeting, I noticed we all had a cup of tea or coffee – so we chatted about where our mugs had come from, and we were surprised that everyone had a tale to tell! How have you made sure the Patient Safety Partners are strategically involved? Some of the infrastructure for involving the Patient Safety Partners at a strategic level was already in place when we recruited them. At the Trust we have safety improvement leads, which each look after a portfolio of safety improvement projects. I work with the leads to understand their projects, whether they are ready for patient involvement, what they require of a Patient Safety Partner and how they would support them. The national framework describes a ‘task profile’ which we found helpful to adopt. With the help of a Patient Safety Partner, I designed a request form for anyone interested in working with them. I manage the process, checking the request and partnering people with Patient Safety Partners based on their interest and capacity. In tandem with their involvement in the safety improvement priorities, we recognise that there is more to be done to drive the ambitions of the framework forward. Early in their tenure, the Patient Safety Partners and I met fortnightly to design our initial strategy for involving patients in patient safety. We used the model for improvement to approach this, and after generating a driver diagram, we broke the work down into five workstreams. These include: Patient Safety Partner programme. Community engagement. Staff engagement and training. Learning response engagement. Equity and inclusion. The Patient Safety Partners expressed an interest in the workstreams and we have at least two partnered with each. Whilst the Patient Safety Partners are involved in lots of work, we are reviewing this to ensure that their participation is meaningful and that they are empowered decision makers. We have recently set up a project team to drive forward improvements in this area. How have you helped the Patient Safety Partners settle in? When I first came into post, I ran a series of sessions to understand how the Patient Safety Partners wanted to work together. We settled on a monthly team meeting and 1:1s. We also drew up an agreement which serves as an agreement between the Patient Safety Partners and any project teams or committees they are working with. When they are partnered with a project or committee, I attend any introductions and their first meeting to ensure their questions are answered and to raise their profile. We have also recently initiated a network of Patient Safety Partners across the Acute Provider Collaborative in north-west London. Some of the Patient Safety Partners at other organisations are working alone, so this has helped them to feel more connected. Have you started to see the impact of the Patient Safety Partner role? One of the places we have seen Patient Safety Partner impact is within our work to engage with patients and families compassionately during learning responses. They co-designed a guide for patients and families and a set of steps for staff to follow. They referenced the PSIRF steps for this but made it more patient-centred. This is then linked to all the resources (eg interpreters) that staff might need to access to support patients and families involved. More recently we have set up a project team to continue driving this work forward and two of our Patient Safety Partners are involved. They’ve already had a huge impact – challenging us to think about learning responses as less of a process and more of the right way to do things. What’s next for the Patient Safety Partners? We have a set of clear routines and ways of working with the Patient Safety Partners and we now need to get to the point where Patient Safety Partners are empowered decision makers, alongside the teams they are working with. To do this we have set up an improvement project and team, meeting fortnightly. We have explored the barriers to being involved meaningfully (eg contributions not being explicitly celebrated, being brought into a project too late, not receiving meeting papers far enough in advance). Most recently, we started generating ideas to address these problems and will be testing them out in the coming months. What have you personally learnt along the way? Personal and professional development of the Patient Safety Partners has been more important than I thought it would be. They are all knowledgeable, skilled individuals, but have areas where they want to build their confidence. For example, one of our Patient Safety Partners has extensive experience with the healthcare system and is keen to tell her story to help others. I found a story-telling workshop for her to attend so she could hone this skill. Another of our Patient Safety Partners has an interest in communications, so we set up a half-day of shadowing with our Communications team. This has been a worthwhile activity and means they can bring even more to the role. What advice would you give someone who is looking to embed the Patient Safety Partner role? Spend time on their personal and professional development. Building on the skills they already have means they feel valued and confident. Be flexible and try to make things work around their schedules. Patient Safety Partners often have other jobs, and this supplements their skills and knowledge, so it’s important we make their involvement easy. Explore a dedicated resource for managing the Patient Safety Partners. This has meant that we’ve done the basics well (eg regular meetings) but are now able to challenge ourselves to make their involvement even more meaningful. Get them involved early on and wherever you can. Even if they don’t have a lot to contribute straight away, they’ll get the context of the work, and it’ll make it easier for them in the long run. Remunerate your Patient Safety Partners. This will ensure the role is inclusive, attracting a diverse group of people and make it so that people can commit their time. If you'd like to hear more about our approach to developing the Patient Safety Partner role, please get in touch with Lea at [email protected]. Share your patient safety insights Do you work in patient safety? Is there an area of your work you'd like to share, or perhaps you have insights to share on a particular patient safety topic? Get in touch with the editorial team if you'd like to discuss an idea for a blog or how to share your resources through the hub - [email protected].

In this blog, we draw on insights shared by Patient Safety Partners and their managers in a recent workshop. The outputs from the workshop, facilitated by Patient Safety Learning and AQUA are being written up into a series of blogs. The first illustrated how a lack of role clarity can be a barrier for impact and the second looked at recruitment and induction.  In our third blog, we share some suggested approaches and actions that Patient Safety Partners and trusts might take to help the role have influence and impact.  The Patient Safety Partner role was introduced in 2022 by NHS England as part of its Framework for involving patients in patient safety and National Patient Safety Strategy. In light of this intention, workshop discussions included an insight-sharing session on how Patient Safety Partners can start to influence an organisation. There was a general consensus that laying the foundations well from the start is key, to enabling Patient Safety Partners to work effectively. Our previous blog on recruitment and induction is a useful resource for this, outlining practical steps that both patient safety partners and trusts can take in the early stages to embed the role well. This blog goes beyond the recruitment and induction stage, as we focus now on what Patient Safety Partners and trusts can do to make sure the role has influence and impact as intended. What can Patient Safety Partners do to start influencing patient safety? The insights shared at the workshop on influence and impact were rich and varied. We’ve drawn on these conversations to suggest some approaches for how Patient Safety Partners can start to positively influence patient safety within their organisation. Get involved on a strategic level Proactively consider where and how the Patient Safety Partner role can support and develop the organisation’s safety priorities. Be responsive to, and familiar with, the Patient Safety Incident Response Framework (PSIRF). Reflect on your existing skills to suggest areas of work that you would be well placed to support. Look and ask “where else can I influence safety”? Build relationships and role awareness Plan formal and informal opportunities to meet staff. Link in with communication teams to help share more internally about your role, your work and how colleagues can involve Patient Safety Partners in their safety improvements . Own and drive the Patient Safety Partner image and involvement Recognise and remember your role is to help improve safety alongside the trust, not against them. Work alongside staff to illustrate the strengths and value of your role and the impact you’re making Patient representatives and Patient Safety Partners have different roles but seek out opportunities to meet and work together. Help shape meetings Review and contribute to agendas in advance. Contribute patient perspectives into safety discussions. Seek to include and hear from voices not normally invited to the meetings. Help ensure community representation across all agendas. Feed back and share how meetings felt for Patient Safety Partners. Change the language and narrative for patient safety to reflect community needs and interests. Advocate for accessible, jargon free language. Be present, be seen, be heard. What can trusts do to help Patient Safety Partners have influence? Workshop participants talked about their experiences as either managers or newly recruited Patient Safety Partners, and how trusts can empower Patient Safety Partners to have influence. We’ve drawn on these conversations to suggest some approaches for trusts. Involve them as strategic partners Proactively consider where and how the Patient Safety Partner role can support and develop the organisations safety priorities. Agree the role of the Patient Safety Partner in decision making. Standardise and normalise the Patient Safety Partner voice being heard at safety meetings. Identify the policies that Patient Safety Partners can read, revise and refresh. Connect Patient Safety Partners to regional and Integrated Care System safety agendas. Involve Patient Safety Partners in work relating to the Patient Safety Incident Response Framework and its implementation . Involving Patient Safety Partners in the Patient Safety Incident Response Framework creates an ideal chance to see how the framework is impacting people and patients. Let their voice determine success. Involve Patient Safety Partners in driving safety surveys for patients and staff, exploring the question “what makes you feel safe?”. Create the right culture Create the conditions where Patient Safety Partners feel welcome, able to and safe to speak and staff want to engage with them. Recognise that your own organisation is potentially an echo chamber, and there is great value in Patient Safety Partners seeing things differently. Make your meetings accessible Review meeting structures that may be intimidating. Use methods and approaches that ensure turn taking (for example, ‘Time to think’). Make sure agendas are shared in advance. Avoid language that excludes (eg acronyms and jargon). Reduce the number of papers and notes circulated. Be person focussed. Use language about people not policies and not pathways. Support relationship-building and role awareness Involve communication and marketing teams to help Patient Safety Partners share messages and how to reach/involve them in safety work. Consider where Patient Safety Partners can link to wider teams (to support safety structure, role recruitment etc). Look for opportunities in professional journals, conferences and events to champion and highlight the impact that Patient Safety Partners are having. If you would like to add to the advice in this blog, please do contact us, we’d appreciate hearing more examples of good practice so we can share widely. Supporting the development of the Patient Safety Partner role At Patient Safety Learning, we continue to work with Patient Safety Partners to share insights and learning for patient safety. We will also be working with AQUA as part of their focus on supporting patient engagement. Together, we’ll be looking at how we can support organisations to gain impact from the Patient Safety Partner role. We would also like to thank the Royal College of Surgeons, Edinburgh for their commitment to patient engagement and their hosting of the Birmingham workshop. If you are interested in this area of our work, please get in touch at [email protected]. Join the Patient Safety Partner Network If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here. If you would like to attend a Patient Safety Partners Network meeting as a guest speaker, please contact us at [email protected]. Related reading Patient Safety Partners – lack of role clarity a barrier for impact (July 2024) Patient Safety Partners: recruitment and induction How do Patient Safety Partners feel about their role? Analysis of online survey results (February 2024) The voice of the patient safety frontline—An introduction to the Patient Safety Partners Network (November 2023)