About Us

We exist to champion safer care across Scotland's health and care system.

Image of the Patient Safety Commissioner Karen Titchener

Karen Titchener MSc NP RN
Patient Safety Commissioner Scotland

My Mandate

Established under the Patient Safety Commissioner for Scotland Act 2023.

  • Independent office
  • Reports publicly to  Parliament
  • Focused on systemic patient safety improvement
  • Authority to investigate themes and make recommendations

Not a regulator. Not a complaints body. Not an inspector.
My focus is system learning and risk reduction.

Key Principles

The Commissioner will ensure that patients, families and the public are listened to and included at every stage of the safety system, particularly those whose voices have historically been marginalised.

Patient experience and lived experience will directly inform priorities, investigations and recommendations.

Why it matters:
TBC

Safety is everyone’s responsibility across health and social care.

The Commissioner will promote whole-system leadership, collaboration and shared accountability so that safety is embedded in everyday practice, not dependent on individuals or isolated organisations.

Why it matters:
No single body can deliver safety alone — it must be built into how the whole system works.

The Commissioner will prioritise learning from patterns, trends and recurring risks, promoting restorative and learning-focused responses to harm rather than blame.

The aim is to redesign systems, so harm is prevented and trust is rebuilt.

Why it matters:
Lasting improvement comes from fixing systems and learning well, not from assigning fault.

The Commissioner will promote a culture of candour, psychological safety and transparency.

Health-care organisations should be open about safety incidents, share learning, and be accountable for acting on recommendations.

Why it matters:
Trust and improvement depend on openness — secrecy allows harm to recur.

The Commissioner will use and promote robust evidence, data, research and lived experience to understand safety risks, measure improvement and guide recommendations to government and health-care bodies.

Why it matters:
Evidence turns individual stories of harm into system-wide action and prevention.

The Commissioner will operate independently of government and health-care providers, acting impartially, proportionately and transparently in the public interest.

Why it matters:
Independence and integrity are essential for credibility, trust and impact.

Decorative image

Patient safety is a system property, not an individual failing; learning, equity, openness, and the right to be heard are central.

 

Patient Safety Charter (Section 6 of the Act)

The Charter explains what patients and families can expect when safety concerns arise, and what the Commissioner expects from health-care providers and public bodies—particularly following major incidents.

Purpose of the Charter

  • To make patient safety expectations clear and public
  • To set out rights, responsibilities, and standards of behaviour
  • To ensure learning and improvement after harm

Who the Charter Is For

  • Patients and families affected by safety concerns or major incidents
  • Health-care organisations and professionals
  • Public bodies and regulators involved in safety oversight

Core Commitments of the Commissioner’s Office

  • The PSC’s office will provide clear routes for people to share their experiences, concerns or ideas about patient safety. We will ensure these voices inform our priorities, investigations and recommendations.
  • You should feel that your concerns are taken seriously, and that what you say helps shape safer care for others.
  • Concerns, trends and patterns raised with the PSC will be analysed to identify systemic risks.
  • Where action is needed, the Commissioner will make clear, evidence-based recommendations to the relevant bodies and follow up on their implementation.
  • You can expect that what you share contributes to real, system-level improvement.
  • The PSC will concentrate on improving the safety of systems rather than on individual blame.
  • Our work will help organisations learn and prevent recurrence of harm.
    We aim to make Scotland’s health-care system safer for everyone.
  • We will explain who we are, what we do, and what we cannot do in plain language.
  • Our communication will be inclusive and accessible to people of all backgrounds.
  • You can expect clarity, honesty and accessibility from our office.
  • Our findings, recommendations and progress reports will be published openly wherever possible.
  • We will explain the reasons for our decisions and share learning across the system.
  • You can expect openness and accountability in how the PSC works.
  • All engagement with patients, families and professionals will be undertaken respectfully and with empathy, recognising the emotional impact of safety incidents.
  • The PSC will ensure that all voices are treated equally.
  • You will be treated with dignity and kindness.
  • The PSC will work collaboratively with health-care providers, regulators, professional bodies and government to address shared safety challenges.
  • Partnership is essential for meaningful and lasting improvement.
  • You can expect the PSC to work with others to make change happen, not in isolation.
  • We will use data, research and lived experience to understand risks and measure progress.
  • Recommendations will always be based on evidence.
  • You can expect that our work is thorough, factual and improvement-focused.
  • When harm occurs, we will encourage organisations to respond with openness, compassion and a commitment to learning.
  • We will support approaches that rebuild trust rather than assign blame.
  • You can expect the PSC to promote healing and learning, not punishment.
  • The PSC operates independently of government, health-care providers and regulators.
  • We will act only in the public interest, guided by evidence and integrity.
  • You can trust that the PSC’s work is free from undue influence.