2025 HSJ Patient Safety Congress – The Good, The Bad, and the Canine.

The Clinical Human Factors Group was out in force at this year’s HSJ Patient Safety Congress in Manchester, where our trustees and ambassadors chaired sessions, gave talks and generally banged the drum for Human Factors. Every year it feels more like a family reunion  – especially at our CHFG dinner at the end of day one where around 40 of us come together to share curry and laughter and generally put the HF world to rights in the best Indian restaurant in Manchester (possibly the world).

In total, Congress featured 44 sessions with 152 speakers across the two days, and was attended by nearly 900 delegates. Our overall impression? A game of two halves. Inspiring one minute, discouraging the next.  A struggle between hope and despair, with no clear winner.

Positives were not hard to find. The scope of the sessions was wider than ever – the usual focus on the acute sector was extended to pay much needed attention to other fields. Mental health was especially well represented, and we heard more from primary care and ambulance services, leaning disability, community, and general practice.

Human factors featured strongly in the programme, largely thanks to our very own COO Dawn Benson, who chaired a series of sessions in a well-attended stream of HF topics. But it was also striking how much HF language penetrated the debate across the congress as a whole, evidence that the tide is turning at last.

There was an inspiring talk from Kelly McGovern, Chief Nurse of Hertfordshire Acute Trust, who shared how she and her team eliminated corridor care. Her approach was refreshingly grounded: working one week in six on the wards, asking services themselves to solve problems, and allowing staff to “break the rules” where this meant scrapping red tape without causing harm. It was leadership rooted in presence, trust, and pragmatism.

One of the most powerful moments came from Joanne Hughes, who beautifully articulated the dual responsibility we have in patient safety work: “The learning response is about looking after the abstract future patient, but we have an obligation with restorative justice to look after the real people that we need to hold and look after now.”

Yet it was sobering to hear from so many people who had been thrust into the world of patient safety campaigning from personal experience of harm. Emma Murphy spoke movingly about her experiences as a victim of fetal valproate syndrome, Kath Sansom recounted her fight for justice after the surgical mesh scandal. We heard from Sandra Igwe, a mother now campaigning against cultural insensitivity and racism in maternity care, and James Titcombe who lost his child to poor perinatal care. Quite apart from the human cost behind these stories, these are patients and family having to take up roles that any functional health system would carry out automatically itself.

With his characteristic mix of humour and poignancy, Jono Broad challenged us to think differently about how we present and value patient experiences. He made the compelling point that when patients share their lived experiences, it’s not a ‘patient story’ any more than a clinician presenting data to the board is a ‘consultant story’. This reframing is crucial – patient experiences are data, evidence, and expertise that deserve the same respect and analytical consideration we give to clinical or financial presentations. They’re not anecdotal additions to the ‘real’ evidence; they ARE real evidence.

The stream on maternity care provided a wealth of thought-provoking insights, but with one common, depressing theme: the failures keep happening, and for the same reasons. Bill Kirkup and James Titcombe pointed out that successive inquiries into maternity scandals make the same recommendations over and over, and little seems to change, and learning never seems to spread. It was therefore interesting to hear them both express a cautious welcome to the recently-announced national inquiry under Baroness Amos. A triumph of optimism over experience? Time will tell.

There was also a sense that national leaders have yet to fully embrace systems thinking. Many of the keynote speakers discussed patient safety almost entirely in terms of ‘toxic’ front line staff and ‘unacceptable’ behaviours at work. They pushed a narrative that getting rid of bad apples, listening to patients, being kind or simply being ‘better’ will fix everything. There was little evidence in the plenary sessions of insight into the systemic vulnerabilities that create unsafe care environments.

Between sessions, the CHFG stand in the exhibition hall was as busy as ever, with scores of interested delegates eager to learn more about our work. This was despite stiff competition from the Support Dogs Charity stand next door, who brought along some of their canine workers – dogs with the barely believable ability to smell when their owner is about to have a seizure. They were the most popular attendees at the event, and arguably the most talented. It makes you wonder whether they could train up some Human Factors dogs, to go and sniff out bad safety culture, or board-level indifference.

Far-fetched? Maybe. But we are CHFG: we leave no stone unturned.