Patient Safety Commissioner: Specialist Reference Group



Baroness Cumberlege’s recommendation for a Patient Safety Commissioner (PSC) stemmed from her findings that patients’ voices and experiences were ignored in the time leading up to the Independent Medicines and Medical Devices Review. Where patients and their families identified and reported harms, these reports were not acted on. She envisaged that the role would seek to address several areas for improvement in patient safety, set out in the report, including:

  • the need for more widespread and timely recognition by the patient safety system of issues identified by patients and public
  • the need for the patient safety system to get better at listening to, and acting on, patients’ experiences of avoidable harm
  • the need to be swifter, and for better co-ordination across and between agencies

Purpose/role of the group

There are already a number of policies in place in Scotland which effectively promote the input of patients and the public to decisions about their care. The then Cabinet Secretary for Health and Sport, Jeane Freeman, was clear that a Patient Safety Commissioner must add value to patients in Scotland – not replicate what already exists. This group mapped out the roles and responsibilities of existing bodies as well as existing policies.

To determine how the PSC will work within existing structures in the Scottish context, the Specialist Reference Group (SRG) ran alongside the Patient Reference Group (PRG). 

Input from both groups informed a public consultation, which ran from March to May 2021. The results of this consultation informing the Cabinet Secretary’s decision on how to progress the appointment


In order to ensure focussed discussions, it is intended that the group is made up of around 12 to 15 members.

Members will be asked to represent their organisation in serving on this group.

Meetings/working methods

The PSC Specialist Reference Group met twice and also interacted by email, via the group

Meetings were minuted.


Where group members were given access to sensitive or confidential information This was made clear by the chair and/or group Secretariat, and members were asked not to share this information more widely.

Interaction with other groups

The PSC Patient Reference Group was made up of representatives of those with lived experience and from the third sector. The key aim of that group was to put forward proposals on what they thought a Patient Safety Commissioner’s role/remit should look like. A member of the PSC Patient Reference Group sat on the PSC Specialist Reference Group, to act as a representative.

Related groups


  • Gordon Johnston, NHS Forth Valley whistleblower champion - chair of Bipolar Scotland, other interests in mental health
  • Jonathan Watt, PASS (CAS) – Patients Advice and Support Service, Complaints and Feedback
  • Lindsay Isaacs, Relationship Scotland – Patient Rights Act
  • Lynsey Cleland, Healthcare Improvement Scotland (HIS) – Director of Community Engagement
  • Mandy Andrew, The Health and Social Care Alliance – Associate Director Partnership Improvement Programme
  • Irene Oldfather, The Health and Social Care Alliance – Director of Strategy and Engagement
  • Manoj Kumar, NHS Grampian – Openness and learning, Scottish Mortality and Morbidity Programme/Team Based Quality Reviews
  • Maureen Stevenson, NHS Dumfries – Duty of Candour
  • Nicola Cotter, General Medical Council – Head of Scotland Office, Realistic Medicine
  • Paul Bowie, NES – Programme Director, Safety and Improvement, Openenness and Learning
  • Sandra MacDougall, Healthcare Improvement Scotland – Interim Director of Quality Assurance, Adverse Events
  • Vivienne Davidson, NHS GG&C – Chair of NCPAS, (NHS Complaints Personnel Association Scotland), Complaints and Feedback
  • Craig White, Scottish Government – Duty of Candour – Deputy Director
  • Susanne Millar, Glasgow Health and Social Care Partnership - CEO
  • Julie Paterson, Mental Welfare Commission - CEO
  • Kate Fearnley, Mental Welfare Commission - Executive Director Engagement and Participation
  • Valerie Malloch, Scottish Public Services Ombudsmen – Legal and Policy
  • John Harden, Scottish Government – Patient Safety -Deputy National Clinical Director
  • Charlie Bethune, PRG representative – Valproate Scotland
  • Susan Cole, Deputy PRG Representative - Valproate Victims
  • Sharon Mercado, PRG Representative
  • Marie Lyon, PRG Representative

  • Donna O’Boyle, PRG chair, Scottish Government

Group management

  • Rosemary Agnew (Chair), Scottish Public Services Ombudsmen
  • Anncris Roberts, Unit Head, Scottish Government – Safety, Openness and Learning Unit
  • Margaret Syme, Team Leader, Scottish Government – Safety, Openness and Learning Unit
  • Pauline Bennett, Senior Policy Manager, Scottish Government – Safety, Openness and Learning Unit
  • Nicki Crossan, Senior Policy Manager, Scottish Government – Safety, Openness and Learning Unit





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