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This blog (attached below) explores how far the nature of our relationships at work have an impact on patient safety. Lesley Parkinson – the executive director of Restorative Thinking, a social enterprise working to introduce and embed restorative and relational practice in the NHS and across public sector organisations – explores how six restorative practice habits add value in multiple teams and scenarios. You can also order Lesley's book Restorative Practice at Work Six habits for improving relationships in healthcare settings.

The Forgiveness Project shares stories of forgiveness in order to build hope, empathy and understanding. Founded in 2004 by journalist, Marina Cantacuzino, The Forgiveness Project provides resources and experiences to help people examine and overcome their own unresolved grievances. The testimonies we collect bear witness to the resilience of the human spirit and act as a powerful antidote to narratives of hate and dehumanisation, presenting alternatives to cycles of conflict, violence, crime and injustice. At the heart of The Forgiveness Project is an understanding that restorative narratives have the power to transform lives; not only supporting people to deal with issues in their own lives, but also building a climate of resilience, hope and empathy.

This series of blog posts is written by a patient who experienced life-changing complications after surgery went wrong. In her posts, they explore the psychological needs of patients following healthcare harm, which are often overlooked during physical rehabilitation. "I believe that the emotional support given to the patient during those first few weeks can make a significant difference to their long term quality of life. That’s why I decided to write this blog, to give constructive feedback to help medical professionals learn from my experiences." Blog posts: It's about acceptance Put yourself in these scenarios Sorry - one important word Reassuring the patient My turn to apologise Emotional support Making ICU a bit more bearable Not what I wanted to hear Helping the patient forgive Not my fault either How time heals Psychological benefits of prehabilitation Talking to an independent person Be kind to angry patients Emotional intelligence Difficult conversations Forget-me-not Surgeons' coping mechanisms Showing his vulnerability A safe place to talk Social media My coping mechanisms Trusting my surgeon again Reconciliation

This new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.

A video of the recent Harmed Patients Alliance webinar on restorative healing after healthcare harm.

Restorative justice is an approach that aims to replace hurt by healing in the understanding that the perpetrators of pain are also victims of the incident themselves. In 2016, Mersey Care, an NHS community and mental health trust in the Liverpool region, implemented restorative justice (or what it termed a 'Just and Learning Culture') to fundamentally change its responses to incidents, patient harm, and complaints against staff. This study highlights the qualitative benefits from this implementation and also identifies the economic effects of restorative justice.

In healthcare systems safety needs to be conceived in a relational as well as a regulatory framework, with resilience being understood as the interplay between both elements. This presentation from the Australian Institute of Health Innovation, critically appraises how harm is understood and responded to within the New Zealand health system and the potential contribution of restorative responses. A major and internationally unprecedented project, that employed a restorative approach to address the harm caused to patients and professionals by the use of surgical mesh in New Zealand (NZ), is used to illustrate the case for change. This webinar discusses: how we currently respond to harm how restorative justice practices differ why restorative justice is important in this complex healthcare environment application to practice.

‘Victim wellbeing’ is a phrase often linked to restorative justice, but what does that look like in practice? In this article, Greg Smith (restorative justice development manager at Thames Valley Restorative Justice Service (TVRJS)), Diana Batchelor (PhD researcher at Oxford University and independent evaluation researcher for TVRJS) and Becci Seaborne (assistant director for restorative justice at TVRJS) consider why, and how, restorative justice could become a default option for health service providers.

Restorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. Restorative practice is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. Could this be something that we could utilise as a new approach in healthcare?

This report summarises the themes that emerged from a restorative process to hear from New Zealand men and women affected by surgical mesh. Restorative justice approaches and practices were used to respond to harm from surgical mesh. This innovation differs to medicolegal action and inquiry approaches in other countries. A restorative approach intended to create a safe space to explore multiple experiences and perspectives of harm. This report, Hearing and Responding to the Stories of Survivors of Surgical Mesh, describes how restorative justice approaches were used to uncover the harms and needs created by surgical mesh use in New Zealand. The actions that consumers and healthcare stakeholders indicated would restore well-being, trust and safe healthcare in New Zealand are included. Skilled facilitators used restorative practices to create a safe space for consumers and health professionals to tell their stories. The same approach supported collaboration between multiple agencies so they could act for repair and prevention. The team that co-created the project includes academics, consumers, facilitators and New Zealand's Chief Clinical Officers. Formal research will evaluate the project next year and consider findings in the context of resilient healthcare systems

Restorative Just Culture aims to repair trust and relationships damaged after an incident. It allows all parties to discuss how they have been affected, and collaboratively decide what should be done to repair the harm.

As patients and families impacted by harm, we imagine progressive approaches in responding to patient safety incidents – focused on restoring health and repairing trust.  We can change how we respond to healthcare harm by shifting the focus away from what happened, towards who has been affected and in what way. This is your opportunity to hear about innovative approaches in Canada, New Zealand, and the United States that appreciate these human impacts.  This interactive webinar was hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization Patients for Patient Safety Global Network. View the webinar on demand and download the slides.

In this blog, Patient Safety Learning sets out its response to NHS England and NHS Improvement’s draft Framework for involving patients in patient safety. We commend the intention and share thoughts on our perspective on this important patient safety issue. We make proposals for how to strengthen patient engagement and co-production. When considering the persistence of unsafe care, a recurring theme that emerges is a failure to involve patients in their own care. Patient safety concerns raised by patients and family members are too often not acted on and, when harm occurs, they are often left out of the investigation process. As set out in Patient Safety Learning’s A Blueprint for Action, we share the view that patient engagement is key to improving patient safety, with this forming one of our six foundations of safer care.[1] The NHS Patient Safety Strategy identifies the involvement of patients in patient safety “throughout the whole system” as a key part of achieving its future patient safety vision.[2] The strategy includes plans to create a patient safety partners framework; earlier this year, the NHS published a consultation on its draft Framework for involving patients in patient safety.[3] In this blog, we will provide a summary of our feedback to the consultation. You can find our full submission at the end of this blog. Involving patients in their own safety The NHS Framework is divided into two parts, the first of which sets out the broad approach that should be taken to involving patients in their own healthcare and safety. We particularly welcome its emphasis on: encouraging patients to ask questions; if problems occur, the importance of providing information and help to maintain patients’ safety; the role of patient incident reports and complaints as a source of learning. In our response, we fed back with our thoughts on improvements in two specific areas - complaints and patient safety incident reporting. Complaints We share the view set out in the Framework that patient complaints should be viewed as “a valuable resource for monitoring and improving patient safety”.[3] We believe it’s important the Framework is joined up with the ongoing work of the Parliamentary and Health Service Ombudsman (PHSO), who have recently completed a consultation on a new Complaints Standard Framework for the NHS.[4] We believe that this presents an opportunity to embed patient safety into these processes and we responded to the PHSO consultation highlighting this. Patient safety incident reporting The Framework highlights the importance of patients reporting patient safety incidents, noting that the future introduction of a new Patient Safety Incident Management System will create “new tools to more easily participate in the recording of patient safety incidents and to support national learning”.[3] We believe more needs to be to be done to address the cultural barriers that deter patients from reporting concerns. Patients, carers and families need to feel assured that their stories and testimonies are welcome. Alongside this, it is crucial that, when concerns are reported, they are used to inform the assessment of risk and patient safety. As noted in the Cumberlege Review, not only are incidents not being reported but the existing systems “cannot be relied upon to identify promptly significant adverse outcomes arising from a medication or device because it lacks the means to do so”.[5] Patient Safety Partners The second part of the Framework is concerned with the newly proposed role of Patient Safety Partners (PSPs) in NHS organisations. PSPs would formally participate in safety and quality committees, patient safety improvement projects and investigation oversight groups. In our consultation response, we highlighted several areas where we feel these proposals require strengthening if they are to be successful. Training and guidance for staff The Framework rightly acknowledges the importance of having appropriate training and guidance for staff to help support the new PSP roles, pointing towards the new National patient safety syllabus as a key source. We have concerns that the National patient safety syllabus, in its current form, does not have a strong enough focus on patient involvement to provide this support. We highlighted the need for a greater emphasis on the skills and knowledge required to understand why and how patients can be actively involved in patient safety in our response to the consultation on the draft syllabus earlier this year.[6] We believe the syllabus could be significantly strengthened by drawing on further research and resources available in this area, such as the World Health Organization (WHO) Patient Safety Curriculum Guide.[7] Support and peer networks for PSPs We believe there needs to be more clarity about the induction and training that would be made available to PSPs. We also make the case that PSPs need access to networks with their peers PSPs in other organisations, enabling them to share good practice for safety improvement and receive support from others. We believe that it would be beneficial to create these networks alongside the new PSP roles. We suggest it would be helpful to draw on experiences of other programmes involving patients in patient safety, such as the WHO Patients for Patient Safety programme in the UK and the Canadian Patients for Patient Safety programme.[8] [9] Patient Safety Specialists The Framework makes brief reference to the relationship between future PSPs and the newly proposed Patient Safety Specialists, which all trusts and CCGs have been asked to put in place by the end of November.[10] We believe that if Patient Safety Specialists are to work effectively in organisations then these roles will need to be filled by leaders with expertise in patient engagement. Responding to a consultation earlier this year, we commented that those filling these roles will need strong skills and experience.[11] We also believe the Framework should place a great emphasis on the role of Patient Safety Specialists in supporting the work of PSPs. Co-production In our feedback, we also argue that there should be a strong emphasis on co-production with PSPs and more broadly throughout this Framework. ‘Co-production’ is an activity, an approach and an ethos which involves members of staff, patients and the public working together, sharing power and responsibility across the entirety of a project.[12] In our view, projects and patient safety programmes should always be co-produced with patients where possible. What needs to be included in the Framework As well as commenting on the specific proposals of the Framework, we identified two additional areas which we believe should be added to it: 1. Measuring and monitoring performance Patient Safety Learning believes that, to make improvements in the involvement of patients in patient safety, we need to be able to clearly measure and monitor our progress. Publicly reporting on changes and improvements made through patient involvement and patient safety allows for sharing examples of good practice. It would also mitigate against concerns that the role of PSP could become tokenistic in some organisations, resulting in little real impact. 2. Restorative Justice Many national healthcare systems and organisations are actively listening to, and engaging with, patients for learning through restorative justice. Restorative justice in healthcare allows patients to be heard, listened to, and respected. By patients, clinicians, healthcare leaders and policy makers engaging with one another on patient safety, it can help to establish trust with the patient. This can also provide the impetus for learning and action to be taken to prevent future harm. We commend the approach adopted by New Zealand’s Ministry of Health in how it responded to harm from surgical mesh and the impact this has had on improvements in patient safety.[13] Closer to home, there are some beacons of good practice within the NHS, such as the Mersey Care NHS Foundation Trust.[14] We believe that the NHS should do more to share and promote a just and learning culture, asking organisations to develop and publish goals on their progress. Only one piece of the puzzle We welcome and recognise the positive steps being set out in the Framework to improve patient involvement in patient safety within the NHS. Our comments and suggestions for improvement are mainly centred around the need to ensure other key pieces are in place. Significant change is still needed. The Framework focuses on increasing patient involvement in governance and decision-making. This wider need for change in how we engage patients in patient safety is outlined in the recently published WHO Global Patient Safety Action Plan 2021-2030.[15] It promotes a range of actions for governments and healthcare organisations to help engage patients and their families in patient safety; we would expect to see this reflected in the work of NHS England and NHS Improvement. Strengthened as we suggest, we believe that the Framework could make a big difference to improving patient involvement with patient safety. References Patient Safety Learning. The Patient-Safe Future: A Blueprint for Action, 2019. NHS England and NHS Improvement. The NHS Patient Safety Strategy: Safer culture, safe systems, safer patients, July 2019. NHS England and NHS Improvement. Framework for involving patients in patient safety, 10 March 2020. PHSO. Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments, July 2020. The Independent Medicines and Medical Devices Safety Review. First Do No Harm, 8 July 2020. Patient Safety Learning. Patient Safety Learning’s response to the National patient safety syllabus 1.0, 28 February 2020. World Health Organization. Patient Safety Curriculum Guide, 2011. Action Against Medical Accidents. Patients for Patient Safety, Last Accessed 15 October 2020. Canadian Patient Safety Institute, Patients for Patient Safety Canada, Last Accessed 16 October 2020. NHS England and NHS Improvement. Patient Safety Specialists, Last Accessed 15 October 2020. Patient Safety Learning. Response to the Patient Safety Specialists consultation, 12 March 2020. Dr Erin Walker, What should co-production look like?, 1 April 2019; National Institute for Health Research, Guidance on co-producing a research project, March 2018. Jo Wailling, Chris Marshall & Jill Wilkinson. Hearing and responding to the stories of survivors of surgical mesh: Ngā kōrero a ngā mōrehu – he urupare (A report for the Ministry of Health). Wellington: The Diana Unwin Chair in Restorative Justice, Victoria University of Wellington, 2019. Mersey Care NHS Foundation Trust. Just and Learning Culture – What it Means for Mersey Care, Last Accessed 16 October 2020. World Health Organization. Global Patient Safety Action Plan 2021-2030: Towards Zero Patient Harm in Health Care, 28 August 2020.

In February 2024 a senior consultant employed by the Royal Devon University Healthcare NHS Foundation Trust (RDUH) was found guilty of three offences; making and possessing indecent images of children (three counts), possession of prohibited images of child pornographic or grossly offensive, disgusting or of an obscene character and possession of extreme pornographic images. This event sent shockwaves through the department they worked in, more broadly across the RDUH and into the population served by the hospital. This event came to light through the courage of a member of staff, who spoke up when they saw something wrong, the actions of staff and the systems in place that contained this situation. The RDUH team worked closely with the Police and other statutory agencies to enable the investigation and bring these events to their final conclusion. The RDUH has commissioned this review, using the principles laid out in a Just and Restorative Culture, to understand the impact this has had on the RDUH and to determine any learning that can be taken from these events. The review concludes with a number of areas where the RDUH could consider improving its systems and process. In most areas there are improvements already underway and the findings in this review could add to them. The review recognises the importance of ensuring the culture of the RDUH in creating conditions where people can speak up and be heard, and for everyone, particularly (but not solely) women, to feel sexually safe at work. The review also offered some opportunity to continue the work that is being done to improve the support for managing doctors well in the RDUH. In particular, the storage and sharing of information, escalation processes and the importance of diverse expertise when managing complex situations are areas for focus. Finally, there is opportunity to improve the process of communication within the RDUH in situations involving confidentiality, safety and where staff are impacted by external events.

Imagine an organisational culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’ It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaboratively addresses the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent. This film documents the amazing transformation in one organisation —Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey toward a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organization to a place where hurt doesn’t get met with more hurt, but with healing.

The stressful nature of the medical profession is a known trigger for aggression or abuse among healthcare staff. Interprofessional incivility, defined as low-intensity negative interactions with ambiguous or unclear intent to harm, has recently become an occupational concern in healthcare. While incivility in nursing has been widely investigated, its prevalence among physicians and its impact on patient care are poorly understood. This review summarises current understanding of the effects of interprofessional incivility on medical performance, service and patient care.