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I have included this poignant video as a matter of public interest. This is an issue which goes beyond party politics. I use Robbie's story in all of my teaching on ethics and clinical governance.

Myths and misunderstandings about prevalent mechanisms to achieve excellence in healthcare.

This document is also attached for download.

The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’. A key action associated with this is a proposal to create Patient Safety Specialists within each NHS organisation in England. The strategy explains that ‘giving everyone in the NHS a foundation level understanding of patient safety is critical, but we also need experts to lead on safety in their own organisations’.NHS England and NHS Improvement have published draft Patient Safety Specialist requirements for public consultation. Patient Safety Learning welcome any increase in patient safety capacity and expertise in the NHS and have provided specific feedback on the draft requirements for this role. In our response we identify several areas where we believe these can be improved, including the following points: Patient Safety Specialists having a clear and direct reporting line to a named executive director on the Board with an assigned patient safety role and to a non-executive director with a similar role. Ensuring that the requirements identify key relationships for the role holders not identified in the draft document: Medical Examiners, Coroners, Healthcare Safety Investigation Branch, Governors, Non-Executive Board Members, HR Directors and NHS Resolution. Including a requirement that Patient Safety Specialists should demonstrate that they have the right skills and experience to work with patients, families and their carers on patient safety issues. They should also show that they can support their organisation to engage effectively in co-production with these groups. The need to strengthen the requirements for the individuals holding these roles to have knowledge and experience of: Investigations, Complaints, Just Culture, Systems Thinking and Human Factors. Giving consideration to how Patient Safety Specialists will engage with frontline staff, who are notable by their lack of reference in the draft requirements.

Hi Sue, can you tell us a little about yourself? My background is in tissue viability and I retain the clinical and leadership role with tissue viability as part of this role. I have been in tissue viability for 17 years and developed and continue to lead the service at Ashford and St Peter's Hospital NHS Foundation Trust. During this time I was seconded into the post of Acting Assistant Chief Nurse 0.5WTE for 1 year. Previous to this, I worked as a Deputy Head of Practice Development and a Ward Sister. You are the first harms prevention nurse consultant in the UK. How did the role come about? The Trust Chief Nurse had the vision to look at hospital associated harms as a whole and how this needs to be managed in a strategic way across the Trust. The role ties in with the NHS Patient Safety Strategy 2019. Where does your role sit within the governance structure? The role sits within the corporate division and has close ties and associations with all of the divisions and their governance structures. The post reports into the Trust Safety and Quality Committee. How long have you been in post? This is the start of my fourth week. What are the main purposes of the role? My role includes: Leading and developing the Harms Free Care Service across the Trust. Developing the Trust Harm Free Care Strategy and monitor its effectiveness. Leading on the Harms Free Care Strategy within the Trust, working with the teams to deliver a sustained reduction in pressure damage, avoidable falls, the absence of a new venous thromboembolism (VTE), harm associated with poor nutrition and the absence of catheter associated urine infection. Being expected to develop and influence strategies and frameworks to ensure that all healthcare staff adhere to Trust policies relating to Harm Free Care, through developing practice linked to the clinical governance and performance frameworks and Trust corporate objectives. Supporting the Trust to develop and implement systems for performance monitoring and performance improvement programmes for pressure ulcers, VTE, falls, nutrition and catheter associated urinary tract infection. Talk us through a typical day. It's a little early to talk about a typical day yet. I still have a clinical role in tissue viability 2 days per week as part of my role and so these days are spent assessing and planning care for patients with complex wound needs, providing education and training. The rest of my time is filled with planning for the role of Harms Free Care, looking at our present data and analysis, meeting with the harms leads, such as the VTE prevention lead nurse and the nutrition lead. Have you had a chance to see what impact the role has had on patient safety? It’s too early to look at impacts, but feedback has been positive that harms must be seen together and not separately. Meaning that we should not concentrate on the reduction of one harm at the potential cost of a rise in another, the harms are interrelated and need to be focused on as such. One of the key parts of the role will be ensuring our metrics in relation to harm are relevant and meaningful to both staff and patients. How are you measuring the impact of the role? There will be multiple measures which will be benchmarked against improvement targets for the reduction of harms. This will include data such as numbers of harms as well as other data such as patient feedback. How do you engage staff and patients in patient safety? We engage staff via various means: education, bulletins, focus days such as Worldwide Stop the Pressure Day, focus weeks such as Nutrition and Hydration Week. We are working towards engagement strategies as part of the NHS Patient Safety Strategy. How do you see this role developing? I would like to see this role being adopted by other Trusts as we have a concerted focus across the NHS to reduce patient harms.

NHS Improvement are asking NHS organisations to identify, by June 2020, at least one person from their existing employees as their patient safety specialist. Training for these specialists will be based on the national patient safety syllabus being developed with Health Education England. Working with representatives from a few NHS trusts, patient safety partners (patient and public voice representatives) and clinical commissioning groups, NHS Improvement have drafted the requirements for a patient safety specialist to help organisations identify the most appropriate person(s) for the role. You can download the draft requirements here. NHS Improvement are inviting comments and feedback on this through their survey which can be accesed via the link at the bottom of this page. Consultation closes 12 March 2020.