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The role of the Patient Safety Commissioner for Scotland is to champion safer care across Scotland's health and care system. This site provides information and resources related to this role. This website includes: Patient Safety Charter - this sets out what the Commissioner expects of health care providers in terms of standards and good practice. Key principles - this statement of the principles informs the exercise of the Commissioner’s functions. Contact information - detailing how patients and the public can get in touch with the Commissioner.

The letter attached is from Professor Catherine Ross, Chief Scientific Officer for Scottish Government, with an update on the work relating to ‘Healthcare Science in Scotland’ and the theme of ‘quality, safety and, assurance’ as set out in Healthcare Science in Scotland: Defining Our Strategic Approach.    The Scottish Government has commissioned the Professional Standards Authority (PSA) to carry out a Right Touch Assurance (RTA) assessment of the Healthcare Science workforce. This work will examine the potential risk of harm to patients, particularly as many roles in Healthcare Science are not currently subject to statutory regulation. The assessment aims to inform future decisions about whether additional regulation may be needed to strengthen quality, safety and assurance across the profession. Stakeholder engagement will form a key part of the process, with opportunities to contribute evidence and views. A final report is expected by Spring 2027, after which the Scottish Government will consider next steps.

Updated polypharmacy prescribing guidance. 'Appropriate Prescribing - Making medicines safe, effective and sustainable 2025-2028' aims to further improve the care of individuals taking multiple medicines through the use of 7-Steps medicine reviews and promotes a holistic approach to person-centred care.

This plan sets out new actions to address health inequalities faced by women and girls in Scotland. Building on the first Women’s Health Plan, these actions seek to advance the Scottish Government's ambition that all women and girls in Scotland enjoy the best possible health throughout their lives. The Plan identifies four priority programmes as part of this second phase of the Women’s Health Plan. These programmes are in addition to, and complement, the 40 actions with the aim of driving forward progress in women’s health. Transformation of Gynaecology Services - The Scottish Government will develop, and NHS Boards will implement, a National Plan for Gynaecology. This programme of service transformation will ensure the timely provision of high-quality gynaecological care which is sustainable for the future. Elimination of Cervical Cancer - The Scottish Government will develop, publish and implement an Action Plan for the Elimination of Cervical Cancer. Women’s Brain Health - Women’s Brain Health will be an early priority for the work of the Brain Health and Dementia Risk Group, led by the Chief Medical Officer (CMO), which is setting national priorities in response to emerging evidence around risk factors for dementia. Innovation to Support Women and Girls - We recognise the transformative impact of innovation and its pivotal role in ensuring women and girls have access to the best-quality care. To support the testing, adopting and scaling of innovations to support women and girls we will explore the innovation opportunities, working with our three NHS Scotland Innovation Hubs and partners across Scotland, around three key priority areas: menopause care and support, gynaecological care and support and data to enable effective design and development of innovation.

The Women’s Health Plan underpins actions to improve women’s health inequalities by raising awareness around women’s health, improving access to health care and reducing inequalities in health outcomes for girls and women, both for sex-specific conditions and in women’s general health. Its ambition is for a Scotland where health outcomes are equitable across the population, so that all women enjoy the best possible health throughout their lives. The Plan is underpinned by the following principles: Addressing inequalities - Responding to the unjust and avoidable differences in people’s health across the population and between specific population groups. Gender equality and intersectionality - Acknowledging and responding to the many characteristics and factors which shape women’s lives such as ethnicity, disability, sexual identity and background. A life course approach - Taking advantage of the different stages in a woman’s life which present both health challenges and opportunities to promote and protect health and wellbeing. Respectful and inclusive services - Everyone who uses and provides NHS services has a right to be treated as an individual and with consideration, dignity and respect. This initial Plan has a specific focus on the following priority areas: ensure women who need it have access to specialist menopause services for advice and support on the diagnosis and management of menopause improve access for women to appropriate support, speedy diagnosis and best treatment for endometriosis improve access to information for girls and women on menstrual health and management options improve access to abortion and contraception services ensure rapid and easily accessible postnatal contraception reduce inequalities in health outcomes for women’s general health, including work on cardiac disease.

Delays in discharging patients from hospital affect people’s physical and mental health, and make it harder to admit others to hospital. This joint report by the Auditor General for Scotland and the Accounts Commission warns this has a significant effect, despite impacting only around three per cent of hospital patients. In Scotland, people medically ready to leave spent 720,000 unnecessary days in hospital in 2024/25. Whilst the full financial impact is unknown, the cost to the NHS in hospital days alone is an estimated £440 million a year. Key statistics highlighted in this report include: 17,915 - Number of times people experienced a delayed discharge in 2024/25 720,119 - The number of hospital bed days lost due to delayed discharges in 2024/25 1 in 9 - Proportion of beds occupied due to delayed discharges in 2024/25 3.2% - Delayed discharges as a proportion of adult inpatient discharges in 2024/25 Report recommendations Jointly, the Scottish Government, NHS Scotland, the Convention of Scottish Local Authorities (COSLA), Healthcare Improvement Scotland, integration authorities and their partner NHS boards and councils, should: Over the next 12 months, develop a consistent approach to evaluating and reporting on initiatives to improve delayed discharges, such as discharge without delay and the Lothian Partnership, and sharing best practice and areas for improvement. Evaluation should be reported annually and include assessing effectiveness, value for money, and whether the initiatives are improving the balance of care. This evaluation should be used to update current discharge planning guidance. In the next six months, publish guidance to clarify and strengthen the role of integration joint boards and health and social care partnerships in the governance and delivery of the health and social care service renewal framework. Over the next 12 months, provide guidance on, and better promote public awareness of the benefits of, establishing a power of attorney or a guardianship order. Over the next 12 months, work together to develop and action an implementation plan to share learning and practice from digital solutions used for tackling delayed discharges, early intervention and prevention, Jointly, the Scottish Government and Public Health Scotland should: Produce a clear estimate of the total costs of delayed discharges and the savings being made through initiatives to reduce delayed discharges. This should be completed within the next 12 months, updated regularly and reported in the annual analysis of delayed discharge performance.

This report summarises the outcome of an unannounced maternity services inspection to the Royal Infirmary of Edinburgh, NHS Lothian on Monday 23 and Tuesday 24 June 2025. This inspection resulted in five areas of good practice, two recommendations and 26 requirements. Healthcare Improvement Scotland summarised their key findings as follows: Throughout the inspection they observed staff working hard to provide compassionate and responsive care in very challenging circumstances. The multidisciplinary team within maternity services spoke highly of the clinical working relationship. In some areas staff were complimentary and described their line manager as supportive. However, the majority of the multidisciplinary team they spoke with expressed feeling frustrated at staffing levels which they believe left areas short staffed and staff unsupported. Staff told them this presented a safety risk for women, babies and families within their care which they raised on multiple occasions with managers. The majority of the staff they spoke with shared their concerns and feelings of being overwhelmed, described feeling unsupported and believed they were not being listened to. Staff informed inspectors this has impacted staff confidence to escalate staffing concerns due to lack of feedback and resolution when concerns are raised. They observed delays to the induction of labour process of up to 29 hours and other delays to women who required ongoing care within the labour ward due to lack of staff availability, capacity and increased acuity. Staff they spoke with described suboptimal skill mix, low staffing levels and high acuity resulting in challenges in providing and maintaining one-to-one care for women within the labour ward. Staff also described staffing impacting on timely care such as delays in undertaking maternity early warning score (MEWS) observations or escalation of clinical concerns. Women told them of mixed experiences within Royal Infirmary of Edinburgh maternity services. In some areas women were highly complimentary of the care they experienced, describing it as exceptional; however, other women described their experience leaving them feeling alone and vulnerable. Whilst some women were complimentary of their care, they also informed inspectors of poor communication, leaving them feeling uninformed and with no ‘voice’ in their care. Their inspection has highlighted gaps in incident reporting and what appears to be a reluctance to submit incident reports with staff describing a culture of mistrust. These are concerning issues that may have significant impact on the learning from adverse events within the system, reducing opportunities to improve safety. During the course of this inspection, Healthcare Improvement Scotland escalated serious concerns with NHS Lothian through the Healthcare Improvement Scotland and Scottish Government Operating Framework. These concerns related to culture, oversight of patient safety and staff wellbeing within Royal Infirmary of Edinburgh maternity services. Other areas for improvement have been identified within maternity services within Royal Infirmary of Edinburgh. These include fire safety requirements, safe storage of cleaning products and required improvements to the environment.

The Office of the Patient Safety Commissioner for Scotland is recruiting for two Policy and Investigations Officers. Closing date:10:00 on 12 November 2025 Further information on the role can be found from the link below. The Office of the Patient Safety Commissioner for Scotland plays a vital role in strengthening the safety and quality of healthcare across the nation. Independent of government and the NHS, the Office amplifies the voices of patients and families, identifying systemic risks and driving evidence-based improvements that make healthcare safer for all. Through rigorous, impartial investigations and constructive engagement with health bodies, regulators, and patient groups, the Office seeks to uncover and address the underlying causes of harm—ensuring that learning from adverse events leads to enduring improvements in policy, practice, and culture across Scotland’s health system. Working with the Commissioner and the Executive Director of Patient Safety, the Policy and Investigations Officer will provide specialist research, investigative and policy support to the Patient Safety Commissioner (PSC) for Scotland. The postholder will lead and contribute to inquiries, reviews, and site-based investigations across NHS and independent healthcare providers. They will ensure that the voices of patients, families, advocacy groups and frontline staff are heard, and that findings inform recommendations and reports to Parliament and Ministers. To be successful in this role, you will have experience in health, policy, regulation, patient safety, investigations, advocacy, or a related area. You should also have proven experience of conducting site-based investigations or inspections in healthcare, regulation or similar settings. It is essential that you have knowledge of healthcare operations, including procedures, waiting list management, medication systems, and medical device use. Strong analytical skills are required for this role, with the ability to interpret and integrate complex information from multiple sources. You should also have knowledge of data protection, confidentiality and ethical frameworks for handling sensitive information.

The Scottish Health Equity Research Unit (SHERU) is a new policy research unit set up to accelerate efforts to improve health and reduce inequalities in Scotland.  The Health Foundation speak to Emma Congreve and Professor Kat Smith, co-leads of the unit, to find out more. 

The Scottish Government needs a delivery plan that clearly explains to the public how it will reform the NHS and address the pressures on services. Despite increasing funding and staffing, the NHS in Scotland is still seeing fewer patients than before the Covid-19 pandemic. Auditors found that: commitments to reducing waiting lists and times have not been met the number of people remaining in hospital because their discharge has been delayed is the highest on record and NHS initiatives to improve productivity and patient outcomes have yet to have an impact and lack clear progress reporting.

At Patient Safety Learning we often get asked by patients and families who have received poor healthcare what they need to do to make a complaint. Although we cannot get directly involved in individual cases, we have put together a simple guides on the step you can take if you need to make a complaint about NHS care in Scotland. We also have the following guides: How do I make a complaint about my NHS care in England: a simple guide for patients and families How do I make a complaint about my NHS care Northern Ireland: a simple guide for patients and families How do I make a complaint about my NHS care in Wales: a simple guide for patients and families How do I make a complaint about my private care: a simple guide for patients and families How do I make a complaint: Sources of help and advice If you are a healthcare professional looking at these pages, the NHS Complaint Standards, model complaint handling procedure and good complaint handling guides set out how organisations providing NHS services should approach complaint handling. They apply to all NHS organisations in England and independent healthcare providers who deliver NHS-funded care. In Scotland, your right to complaint is covered by the Charter of Patient Rights and Responsibilities. The Charter explains your rights to: Give feedback, make comments or raise concerns or complaints about the healthcare you receive. Be told the outcome of any investigation into your concerns or complaints. Have independent advice and support when providing feedback. Take your complaint to the Scottish Public Services Ombudsman (Ombudsman). Step 1: Frontline resolution Since April 2017, the NHS in Scotland aims to deal with more straightforward complaints within five days. This is known as frontline resolution. If you have a concern about health or social care issues, you can complain to any member of staff or ask to speak to the Feedback and Complaints Officer for the NHS organisation involved. If you are still at the place where you have received care, you can raise your concerns with the GP, nurse or other health professional you are dealing with. They may be able to resolve the complaint immediately and offer an apology. You can complain directly to the provider (GP practice, NHS dentist or hospital). If you do not wish to deal directly with the provider or if your complaint involves more than one NHS provider (such as a GP and a hospital or more than one hospital) the NHS Board can enable a co-ordinated investigation and response. Find your local NHS Board. Specific contact details for complaints can be found at NHS Inform. The provider will consider if the matter is a complaint and whether the issues are relatively straightforward and can be resolved with little or no investigation. If so, your case will be dealt with under frontline resolution. If your complaint is not resolved, see Step 2: Investigation. Step 2: Investigation This is the complaints handling process for cases which have not been resolved at the frontline stage or where the complaint is complex, serious or ‘high risk’. When will stage 2 be triggered? If frontline resolution has been attempted but you remain dissatisfied and request an investigation; this may happen immediately after the frontline stage decision or sometime later. If you refuse to take part in frontline resolution. If the issues raised are complex and require detailed investigation. If the complaint relates to serious, high-risk or high-profile issues. AvMA (Action against Medical Accidents) has a number of self-help guides that provide clear and straightforward explanations of the procedure and guide you through making a complaint, including a helpful template letter. The investigating officer may wish to contact you to discuss the scope of their investigation and to see whether the resolution you are seeking is achievable and realistic. They may ask you for additional information needed to investigate the complaint and should explain if they are going to seek such additional information. At this point they may offer you a meeting or telephone call to discuss the complaint. You do not have to agree to this. You should receive a full response to your complaint, by your preferred method of communication, within 20 working days. If you are not satisfied with the outcome but think that the provider could still put things right, you should respond setting out what you are unhappy with and how you think it could be resolved. If you do not think your concerns can be settled by the provider, you can contact the Scottish Public Services Ombudsman—see Step 3. Mediation is a service where independent mediators help the relevant parties to reach an agreement. You can request, or health boards may offer, to provide this service. Both parties must agree to take part before this can go ahead. You can get help finding mediation services in your area by asking the Feedback and Complaints Officer at your local health board. Step 3: Scottish Public Services Ombudsman If you are dissatisfied with the response you have received then you can contact the Scottish Public Services Ombudsman. Before you approach the Ombudsman, you must have completed the local resolution complaints process above. You will need to put your complaint in writing and include copies of all correspondence from the local resolution stage of your complaint. You should make your complaint to the Ombudsman within 12 months of the events or incident in question, or within 12 months of you becoming aware that there were grounds for complaint. Step 4: Judicial review In some cases, it may be appropriate to use the judicial review procedure, particularly if you urgently need to challenge the way in which the NHS has made a decision which affects you (for example, not to provide certain treatment). The Court of Session in Edinburgh can: Look at how the decision was made on a procedural basis. This is not an appeals process and cannot change or reverse the actual decision. Check that the NHS did not abuse its powers. Check that the NHS acted properly and lawfully. Judicial review is a remedy of last resort and is only very rarely applicable to NHS complaints. You will need specialised advice from a solicitor on whether there are grounds to apply for judicial review. The Law Society provides a list of lawyers who specialise in medical matters.