Patient Safety Commissioner Specialist Reference Group minutes: January 2021

Minutes from the meeting held on 20 January 2021.

Attendees and apologies

  • Rosemary Agnew, Scottish Public Services Ombudsman, Chair
  • Gordon Johnston, NHS Forth Valley
  • Charlie Bethune, patinet representative
  • Gill Davies, Patient Advice and Support Service
  • Lynsey Cleland, Healthcare Improvement Scotland
  • Donna O’Boyle, Professional Regulatory Adviser, Scottish Government
  • Margaret Syme, team leader, Scottish Government
  • Pauline Bennett, Senior Policy Manager, Scottish Government
  • Valerie Malloch, Scottish Public Services Ombudsman
  • Nicola Cotter, General Medical Council
  • Moira Nicholson, Scottish Independent Advocacy Service
  • Jean McQueen, Healthcare Improvement Scotland
  • Marie Lyon, patient representative
  • Sharon Mercado, patient representative


  • Craig White
  • Alison Crooks
  • Kate Fearnsley
  • Irene Oldfather
  • Lindsay Issacs

Items and actions


  • welcome, introductions and apologies 
  • minutes and actions
  • feedback from the Patient Reference Group
  • Scottish Government update
  • breakout room discussions
  • breakout room feedback and discussion
  • future meetings and next steps
  • any other business

Welcome, introductions and apologies

RA welcomed everyone to the meeting, noting apologies and acknowledging the new members - JcM and MN who replaced LI. RA also welcomes the two new additional Patient Reference Group reps ML and SM to the group.

Minutes and actions

The minutes from the last meeting were agreed, and the two actions arising are covered in this agenda.

Feedback from the Patient Reference Group (PRG)

CB from the Patient Reference Group gave an update on the last patient group meeting. CB updated the group on the decision to include additional PRG reps to the SRG.

Scottish Government update

The first draft of the consultation has been amended following feedback from the PRG members; the second draft is currently circulating within Scottish Government policy colleagues with an interest. It will then be shared with this group, and once all feedback has been received the consultation will be updated, and shared with the Cabinet Secretary for her comment and agreement to publish. The aim is to publish the consultation early February subject to Cabinet Secretary approval.

Update on action 2 from the previous meeting (SG policy team to draft a survey/questionnaire and share for input and discussion). This was not possible as John Connaghan, in his role as acting Chief Executive of NHS Scotland has introduced a new internal process for requesting information from Boards – this has been introduced to lessen the burden on the ask of Boards by SG given current pressures.

SG policy have pulled together a paper outlining the current landscape, and suggest that this is used in lieu of issuing a survey/questionnaire to Boards; secretariat will forward this to the group to comment and update as necessary.


  • SG policy team to share updated consultation for input ahead of publication


  • SG to forward landscape paper for comment

Breakout Group discussion 

The meeting split into two groups to discuss to discuss the following:

  • defining and mapping the current patient safety landscape in Scotland
  • identifying the challenges in hearing the patient voice effectively

Defining and mapping the current patient safety landscape in Scotland:

  • lack of knowledge on where patients/public can go with concerns
  • current landscape could be better at dealing with long-term/or with queries
  • often point of contact is clinician who delivered care
  • how are emerging issues identified when treatment is in line with current practice
  • could intelligence be better co-ordinated
  • are we utilising the third sector, e.g. for signposting, etc
  • can lessons be learned from the 'Who to go to campaigns'
  • is there a need for more mandatory reporting
  • sharing intelligence group publish a report with themes, how do other organisations use data gathered

Identifying the challenges in hearing the patient voice effectively:

  • current landscape is complex and there is potential for it to become fragmented, and difficult for people to navigate
  • this might mean that key pieces of the jigsaw don’t come together easily where there are patterns or incidents happening but they are seen in isolation
  • who does the current landscape protect: the organisation, patients, staff or all of them
  • how do we make sure patients/patient voice always at the centre of their care
  • still a fear of blame culture which may be limiting learning
  • does making a complaint about a healthcare provider or clinician lead to issues with continued care
  • how do the organisations in the current landscape receive and share information as GDPR makes this more difficult
  • some group members had heard of National Safety Alerts Oversight Group – how can their role be publicised more, including their involvement in any national issues
  • has Duty of Candour made an impact, and are patients kept informed

Discussion following breakout session

Brief discussion followed, and general agreement with feedback from discussion groups. 

Future meetings and next steps

The intention is for the group to meet again in the summer once the consultation has been analysed and the report is available. Between now and then, any contact will be via e-mail. However there may be a need to meet before the summer. The same approach has been agreed with the patient group.


  • SG policy team to arrange group meeting after consultation and once report has been published

Any other business

There was no other business and RA brought the meeting to a close.

 Action summary

  • SG policy team to share updated consultation for input ahead of publication
  • SG to forward landscape paper for comment
  • SG policy team to arrange group meeting after consultation and once report has been published
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