Patient safety

We regularly review data from multiple sources. This helps us to understand what is happening across our services. It also helps to identify areas where we can improve. We use this information to develop our patient safety incident response plan (PDF, 486 KB). We sometimes call this a PSIRP. This plan explains how we will learn from patient safety events such as incidents.

We approved our second patient safety incident response plan in December 2023. This plan aims to align with the NHS patient safety strategy by:

• compassionately engaging and involving people affected by patient safety incidents
• promoting the use of a range of system-based approaches to learning
• showing a considered and proportionate response to patient safety incidents
• aiming to have a supportive oversight which is focused on strengthening how we respond and function as a system and deliver improvement

Our patient safety incident response plan adopts a just culture approach to learning. This means people feel safe to raise a safety concern because they know our response will be compassionate and fair.

We undertake patient safety incident reviews and investigations to identify new opportunities for learning and improvement. All patient safety reviews and investigations focus on how to improve healthcare systems. They do not look to blame individuals. When we include blame or try to decide if an incident was preventable we can create a culture of fear. This can restrict our ability to learn. There are other processes and organisations who look at criminality, culpability, and cause of death.

We have appointed 1 patient safety partner. This is a member of the public who will help us make sure we consider what we do from the patient's point of view.

We want to recruit more patient safety partners. It is important for us to hear from people with different points of view. You can find out more about patient safety partners further down this page.

Patient safety incident investigation: pressure ulcer care

We investigated why a patient's pressure ulcer was getting worse.

Our community nurses and a care agency were caring for the patient. We found that care agency staff received different pressure ulcer training.

As a result, our Tissue Viability Team has made pressure ulcer prevention training available to care homes and care agencies. They are invited to attend pressure ulcer prevention groups where learning and training is included.

Patient safety incident investigation: medication

An investigation into a medication incident on a ward found staff had limited access to hard copies of the British National Formulary (BNF).

We have now made the BNF available online. Staff can access this from any Trust computer.

Learning from experience: leg ulcers

Our Community Nursing Team looked after an 86-year-old gentleman's chronic leg ulcers. As part of his treatment, he was given special boots to wear. This is because he was unable to wear his own shoes. The special boots are designed to allow patients with bulky bandaging to move around safely. They also take the pressure off the feet to help prevent pressure ulcers. Despite this, the gentleman developed a pressure ulcer on his heel.

When we looked at his care, we found it was hard for the nurse to view the man's heel. This was because of his limited mobility. It was also unclear how long patients could safely wear the special boots.

To prevent this happening again, we now provide nurses with mirrors. We also contacted the manufacturer to clarify how long people could wear the boots. Once we had this information, we shared it with the staff who prescribe the boots. We are looking to see if there are other products which can be worn safely for longer.

Keeping you safe is our priority. We will do everything we can to stop people coming to harm. However, sometimes things go wrong.

When things do go wrong, we want to involve patients, their families and carers. This helps us work out what went wrong and what we can learn.

If you or a family member is involved in an incident, we will contact you. We will want to talk about what happened. We will tell you what we know about the incident. This is part of our commitment to being open.

When an incident causes a certain level of harm, we must be open and transparent. This is a legal requirement. We will tell you what happened and what we plan to do. We call this process Duty of Candour.

Under Duty of Candour, we will:

• apologise in person and tell you what has happened
• work closely with you to understand why it happened
• meet with you to discuss what we found

When we carry out a further review or investigation, the aim is to identify any lessons we can learn. This helps us to improve the care. It can show us things we can do differently to prevent a similar incident happening again. When we do this, we will explain what is involved so you know what is happening and what to expect.

You can contact the Patient Safety Team. There are lots of ways you can get in touch:

• write to: Patient Safety Team, Suite 6, Carew House, Beacon Technology Park, Boundary Road, Bodmin, PL31 2QN
• email the Patient Safety Team

Please only tell us about patient safety at Cornwall Partnership NHS Foundation Trust. Patient safety at other organisation or hospitals, you need to raise it with that organisation.

If you want to raise a concern or complaint about our services, our Complaints Team can help.

If you want to complain about your GP or the practice, you need to contact them direct. Find a GP service. The practice website will tell you how to get in touch and make a complaint.

How you can get involved 

You can use any of the methods above to contact us. For example, you may want to tell us about a safety issue you've experienced. You can also tell us if a friend, carer or family member was involved in a safety incident.

You can also tell us if you think something was really good. It helps us to know what we should do more of and what matters to you. You feedback helps us make our services better.

Become a patient safety partner

Patient safety partners are volunteers from our local community. They share their point of view and work with us. Together we can make change happen and improve patient care.

Patient safety partners help to remind us about the importance of listening to patients, families, and carers.

If you want to be a patient safety partner, send an email to our Patient Safety Team.  You can also phone us on 07920 757 327.

• Patient safety partners application form Microsoft Word format (DOCX, 67 KB)
• Patient safety partners application form PDF format (PDF, 229 KB)

Please return completed forms to our Patient Safety Team.

Patient safety rights charter

The World Health Organisation developed the Patient Safety Rights Charter after the World Patient Safety Day in 2023. The day focused on patient engagement linked to patient safety. Its aim is to support the implementation of the global patent safety action plan for 2021-30 toward eliminating avoidable harm in healthcare. Our policies, procedures and values align with the principles of the Patient Safety Charter.

Framework for involving patients in patient safety

The Involving Patients in Safety Framework sets out how NHS organisations should involve patients in patient safety.

NHS Patient Safety Strategy

The 2019 NHS Patient Safety Strategy recognises the importance of involving patients, their families and carers and other lay people in improving the safety of NHS care, as well as the role that patients and carers can have as partners in their own safety.

Patient Safety Principles

The Patient Safety Principles were developed by the Patient Safety Commissioner. They provide a framework for decision making, planning and collaborative working with patients as partners in a just and learning culture and are for everyone working in the healthcare system.

NHS England's Patient Safety Incident Response Framework

The Patient Safety Incident Response Framework sets out the NHS's approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.

NHS England have produced a series of patient story videos to be used as training resources for NHS organisations to demonstrate the impact the initial response to a patient safety incident and subsequent investigation has on the patient

Kathryn's story

Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed.

Kirsty's story

Kirsty talks about her experience following an incident where there were problems with care during the delivery of her third child following the administration of a Syntocinon drip.

Valerie's story

Valerie, a patient with Parkinson's disease, talks about her experience following an incident where she was mixed up with another patient and given the wrong medication.