Patient Safety Commissioner - Specialist Reference Group: terms of reference

Terms of reference for the Patient Safety Commissioner - Specialist Reference Group.


Baroness Cumberlege’s proposal for a Patient Safety Commissioner (PSC) stemmed from her findings that patients’ voices and experiences were ignored in the time leading up to the 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 Cabinet Secretary for Health and Sport has been clear that a Patient Safety Commissioner must add value to patients in Scotland – not replicate what already exists. This group will map out the roles and responsibilities of existing bodies as well as the existing policies

To determine how the PSC will work within existing structures in the Scottish context, the Specialist Reference Group (SRG) will run alongside the Patient Reference Group (PRG).  
Input from both groups will inform a public consultation, with the results of this consultation informing the Cabinet Secretary for Health and Sport’s decision on how to progress the appointment.


The full membership list for the group can be found at Annex A.

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

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


Meetings will only go ahead if there is a minimum of six people (excluding Group Management) in attendance.

Meetings/working methods

The PSC Specialist Reference Group will meet virtually and as frequently as the PSC Patient Reference Group.  In between meetings the group will interact by email, via the group Secretariat (

Members of the group may contribute suggested agenda items and papers for meetings, through the group Secretariat, no later than six working days in advance of meetings.  The group Secretariat will aim to circulate agendas and papers no later than five working days ahead of meetings. 

Meetings will be minuted, with minutes circulated amongst the group for comment/clearance within five working days of the meeting taking place.  However, this should be a safe space for members to speak freely.


There may be times when group members are given access to sensitive or confidential information.  The chair and/or group Secretariat will make it clear when this is the case, and members are asked not to share this information more widely.

Interaction with other groups

The PSC Patient Reference Group is made up of representatives of those with lived experience and from the third sector.  The key aim of this group is to put forward proposals on what they think a Patient Safety Comissioner’s role/remit should look like for advice and guidance from the PSC Specialist Reference Group.  A member of the PSC Patient Reference Group has been invited to sit on the PSC Specialist Reference Group, to act as a representative.

Annex A

Group membership

  • 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
  • Gill Davies, PASS (CAS) - Patients Advice and Support Service, Complaints and Feedback
  • Ann Pullar, Scottish Government -  Health Technologies
  • Lynsey Cleland, Healthcare Improvement Scotland (HIS) – Director of Community Engagement
  • Mandy Andrew, The Health and Social Care Alliance – Associate Director Partnership Improvement Programme
  • Irene Oldfathe, The Health and Social Care Alliance – Director of Strategy and Engagement
  • 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
  • Jean McQueen, NES - person centred care and education for staff
  • Sandra MacDougall, Healthcare Improvement Scotland –  Interim Director of Quality Assurance, Adverse Events
  • 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
  • Marie Lyon, PRG Representative -  
  • Donna O’Boyle, PRG chair, Scottish Government, 
  • Moira Nicholson, The Scottish Independent Advocacy Alliance
  • Sharon Mercado, PRG representative

Group management

  • Rosemary Agnew (Chair), Scottish Public Services Ombudsmen
  • Margaret Syme, Team Leader, Scottish Government – Safety, Openness and Learning Unit
  • Anncris Roberts, Unit Head, 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, Openess and Learning Unit
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