Patient Safety Commissioner Karen Titchener: MSPs should be worried about me

Karen Titchener was a hard woman to find. 

The Scottish Government wanted to recruit its first-ever patient safety commissioner, but the right candidate was proving elusive. The first round of recruitment failed to produce anyone suitable. The second saw a candidate selected – who then backed out. Then, at the third time of asking, Titchener came forward.

It was the fact the job seemed so difficult to fill that attracted the former nurse to it. Planning a move back to the UK from America, she spotted a story about the second unsuccessful round and wondered what it was all about. “I thought it was either a poisoned chalice or the fact no one had done it before – there was no blueprint – had put people off,” she recalls. She watched for the readvertisement coming and went for it. “I liked what it was going to do, I liked the fact that this role was going to truly, through listening to patients, change healthcare.”

“MSPs should be worried,” she tells Holyrood in her Edinburgh office, “because I’m exposing the issues with health in Scotland.” It’s often stated, she says, “that we are good, and I’m not sure of that”. “We do some things very well”, she goes on. But there is a caveat.

“We need to be considering, are we doing our best, are we being transparent and open and do we truly feel, as government and as health boards, that we can put our heads down on our pillows at night and our best is good enough? 

“I’m not sure too many people should be having a good night’s sleep.”

Created off the back of women’s health scandals – transvaginal mesh and birth defects caused as the side effects of prescription drugs – Titchener’s job is independent of both the government and the health service and was unanimously backed by MSPs in a 2023 vote. 

The job comes with a £90k-plus salary and an eight-year contract. It involves advocating for systematic improvement in healthcare safety and promoting the importance of patient views and experiences. And it comes years after England installed its first such commissioner.

Dr Henrietta Hughes has been in post there since 2022, thanks to the Boris Johnson government. Medical scandals revealed how women were ignored or dismissed by the medical establishment and a review recommended the creation of the role.

When the creation of Scotland’s commissioner was approved, public health minister Jenni Minto said the move would “go a considerable way to making health care safer for us all”. Today, Titchener says she’ll make sure of it. “In the early days, success will be that patients actually feel that they have a voice and they are influencing change,” she says. 

“We are not listening. I’m hoping that through listening to the patients we actually catch things earlier and we stop ‘never events’ and we stop poor behaviour and we stop poor care.” Which sounds, in all honesty, like a tall order. But Titchener isn’t fazed. “I have always done the big-picture stuff,” she says.

And with more than 20 years of experience in the health sector and a career that has taken her across time zones, it’s easy to see why her CV impressed. Prior posts include running hospital at home services in England and America. “I didn’t set out to be ambitious,” she says of her career, “but I seemed to always go for something that was a bit beyond where I was and get it.”

It all started in a cottage hospital in Northern Ireland. Originally from Portadown in County Armagh, she began nursing on her 18th birthday and recalls serving under a matron who ran the place with iron discipline. “Oh my gosh, it was so scary, honestly,” she remembers. “We were terrified in case our hospital corners [on sheets] weren’t right.”

The young nurse coped in part due to her “very religious” upbringing in a Baptist household which attended church multiple times a week. “You were used to that authoritarian way,” she says. 

In my previous roles I’ve been the problem-solver, but I’m probably not the fixer here

An achiever from an early age, she did well because she “wanted to please the teachers”, becoming deputy head girl and picking up instruments and sports gear. Keen on tennis, she had Wimbledon in her sights; adept at hockey, she imagined entry to the Irish national team. “I played for Portadown’s first 15, and a lot of those players played for Ireland,” she says. “When I started my nursing, they wouldn’t let me in the first 11 because I worked shifts and I couldn’t guarantee I would be there every Saturday.”

But she has no regrets about pursuing her medical career. “My love is just for patients and making sure that everything I do is to the best of my ability for them,” she says.

That love of healthcare has been passed down to her three children, all of whom work in the sector: her son is a paramedic with the London Ambulance Service, while one daughter is a paediatric nurse and another a management consultant in healthcare. Only her husband, a retired car salesman, is left out of the family business. “He could sell holy water to the Pope,” Titchener laughs.

The pair started married life in Guildford, where Titchener worked in nursing homes and community nursing. When she started doing house calls for a “very busy” GP surgery in rural Surrey, she would work nights and come home to take over parenting duties when her husband went to work. “I just didn’t sleep,” she says. “I think I just have that survival spirit.” 

And, moving between posts, she loved the work. Apart from a spell as a school nurse. “I couldn’t sleep at night worrying about the children,” she explains. “I couldn’t separate life from that.” She remembers siblings who were “falling off” the developmental charts, and who were so unkempt that teachers kept facecloths for them. Titchener reported the situation to a social worker. “They said ‘there’s nothing to see here’, and I said, ‘it’s your name I’ll be giving to the press if something happens’, so we then did have a case inquiry and those kids did get taken away to foster care, thank God.”

She would go on to become a leading proponent of hospital at home programmes, working to identify and close gaps in service, developing clinical pathways, and building the teams and processes to do it. Working long days in London, Titchener commanded teams at Ealing and Guys & St Thomas’ hospitals, managing budgets of up to £1m and seeing more than 100 patients per day. She studied similar initiatives in Australia and New Zealand to look for lessons she could bring back, but found curious authorities there equally interested in what wisdom she could offer them and spent much of her time imparting rather than collecting knowledge.

And then came America, with Titchener moving to Utah, where she spent several years working at the Huntsman Cancer Institute in state capital Salt Lake City, building an oncology hospital at home programme to serve urban and rural communities in a country where care is commodified. Entering that world, Titchener says, was at first “bizarre”. 

But, she says, she “learned a lot”, moving on to work for a company that specialised in helping health systems adopt their own clinical models for care in the home. “In America, when it’s purely money-driven they give you 10, 11 lines of treatment. Is it life-prolonging? Probably not. Within our project we ended up having very good guidelines of care and conversations with patients, saying ‘the treatment isn’t reversible, your cancer is life-limiting, what do you want to do with the rest of your life?’ Some people said they wanted to fly, they wanted to do a road trip, so then it was, ‘okay, what do we do about your treatment?’ When you’re a vulnerable patient you just listen to doctors and if the doctor says ‘we have to do this’, there’s often no questioning of that. But we had time to have good conversations with them.”

The process was about providing some agency to patients who might otherwise feel disempowered, Titchener says. And one of the most important things that she has learned to make it all happen is “what it is that I need to give people in order for us to move forward” – how to open doors and make change. “In my previous roles I’ve been the problem-solver, but I’m probably not the fixer here,” she says of her new job. 

And indeed, it comes with a clear remit: don’t pick up cases for individual patients – they belong with the Scottish Public Service Ombudsman (SPSO) – and don’t set or monitor standards – that’s a task for Healthcare Improvement Scotland (HIS).

Distinct from those, the commissioner can carry out formal investigations across the NHS and independent systems, moving to do so where there are wider concerns about safety and practices, informed always by patient reports. Crucially, the job comes with the authority to mandate the provision of information. 

Titchener is speaking with the ombudsman and HIS to determine how they can best work together. “We do still have to compartmentalise,” she says, but wants to know “what happens if five patients make the same complaint” to another team. “I have been saying to them, ‘if you have themes emerging about this hospital or this A&E, then share it with me’. They can’t investigate systemic failings or problems.” 

We cannot get change if there is no accountability

Such failings and problems include the area of maternity care. “It’s a national concern that standards aren’t living up to how they should be,” Titchener says.

Chaired by Minto, whose remit includes women’s health, and reporting to health secretary Neil Gray, a specialist maternity and neonatal taskforce was set up in January to bring “continuous, evidence-informed improvement” in the wake of damning reports across Scottish services. Five papers by HIS revealed concerns over staffing, care delays and deficiencies in learning from adverse incidents. 

At Ninewells Hospital in Dundee, delays in labour induction of up to 72 hours were reported and there were insufficient monitoring devices for fetal heart and uterine activity. At Edinburgh Royal Infirmary, women said they had been left alone in triage rooms without call buttons for long periods of time. At the Western Isles Hospital, HIS found a lack of risk assessments and guidelines to identify women or babies who required transfer off the island for care. At Crosshouse Hospital in Kilmarnock, there were gaps in incident reporting. And many personal stories have emerged, with some women forced to travel long distances for care and more than £96m paid out in maternity and obstetric negligence cases between 2020-21 and 2024-25.

Gray has said his family was affected too, telling the chamber that he “very nearly lost” his wife “due to inaccurate assessments of ectopic pregnancy symptoms”. “This is an incredibly sensitive and emotive issue, and it is one whose effects will be felt across the chamber,” he told MSPs.

And so there is consensus that standards must be driven up. But while some would want to see a public inquiry established, Titchener is against this. “I worry about inquiries and task groups because, for me, maternity needs sorted now, not in five years,” she told a recent meeting of the Scottish Parliament’s Health, Social Care and Sport Committee, “so if it went to an inquiry that would be a bad thing for maternity and for patients. The service needs to be redesigned. It needs people in a room with a whiteboard saying, ‘what we’re doing is not working for patients, so how can we move it forward?’

“Having many years of big operational experience, I know that that is not my job, so I have to pull back and say, ‘I can’t sort everything’. However, let us consider not inquiries but service redesign and change.”

“There’s too much that’s not working well,” she tells Holyrood, and she’s preparing to get out into communities to find out more. Titchener is undertaking something of a tour around the country, meeting maternity groups in communities like Caithness and Orkney. She’s already been to Stranraer and will go to Perth and Kinross next month.

She says she wants to be “forward-facing for everybody” and is talking to organisations like Alliance Scotland and the Neurological Society as she works out “different ways to meet everybody’s needs”. She’s looking for an open dialogue, even where that’s difficult. And she wants that culture to permeate the health service. 

At the moment, she’s concerned that this doesn’t exist within the sector – at least not to the extent that it should. Because although she doesn’t handle whistleblowing, she’s hearing from staff who are telling her their concerns are  being squashed. “I’m being told ‘we are being shut down’. If we have got that, God help us. Why aren’t we doing absolutely everything we can to stop another Eljamel happening?” she asks, referring to the NHS Tayside neurosurgery scandal which saw patients subjected to botched operations by a surgeon who was working above his skill level and without safeguards.

Sam Eljamel was subject to light-touch “indirect” supervision before being removed from his post at Ninewells Hospital. Bosses failed to recognise serious issues with his performance and even after being put under supervision he carried out more than 100 operations within just six-months. Patients were left with life-altering injuries and in one case he removed a woman’s tear gland instead of a tumour. 

A dedicated public inquiry is ongoing and, speaking to MSPs, Titchener said she was “not confident” that sufficient change had been made across the sector to prevent another malpractice scandal like it. “Obviously there is an ongoing inquiry in that regard, and I do not want to muddy the waters, but I would say that, even within the board where that happened, there are still concerns,” she said. 

That the NHS in Scotland is too quick to close ranks is an opinion shared by Conservative MSP Sandesh Gulhane, a GP. A culture of “shutting down staff and gaslighting families” is “not new”, he told Titchener in that committee session. “I have been in the NHS for almost two decades and that culture has been there the entire time that I have been there. That is because our management are working with complete impunity. Nothing affects them. At the end of the day, when scandals break, something happens, and we move on, but nothing happens to the management.”

This is about everybody’s human rights

“I agree,” Titchener told him. “I think that accountability is the biggest failing, because people hide behind the institution. Absolutely, accountability is one of my first things that I will be looking at. That is not about blame, but we cannot get change if there is no accountability and people are not speaking up and saying, ‘yeah, we got that wrong’. That is what most of the patients want to hear.”

There is, Titchener says, an issue of regulation. Working in England, she was used to the Care Quality Commission, which regulates that country’s health and social care providers. In contrast, HIS has an inspection and improvement remit, something Titchener has described as being both “good cop and bad cop”. It does have “hobnail boots”, she says, noting the power of its improvement edicts where standards are found to be failing. But the landscape in England, she says, “feels much more regulated”. 

While she was appointed in September, Titchener’s office is still so new that she’s yet to have her website set up. She’s based in the same building as HIS and the SPSO, as well as the Scottish Biometrics Commissioner and the Scottish Human Rights Commission. The premises sits close to Leith Walk, and Titchener’s part, with its fresh white walls and sparse furniture, has the air of a space that’s not yet been fully broken-in. She’s found Edinburgh’s winter cold, the city’s winds cutting, and she regrets not always taking her gloves with her. But she’s relishing her new role, even though it brings many challenging issues.

One of these is the availability of single-sex spaces and services within health. She’s concerned about the findings of a 2025 report which exposed sex attacks and rapes within hospitals, and she wants to know more. Women’s Rights Network Scotland, which compiled the data, wants to see female-only provision enshrined within NHS practice, but critics say this could make life difficult for transgender people. 

Then there’s the Sandie Peggie tribunal, which was concerned with the decision of NHS Fife to allow a transwoman medic to use female changing facilities. Peggie was suspended from work after making a complaint and the tribunal found she had been harassed by the health board but dismissed other allegations of discrimination and victimisation. The result is now subject to appeal. 

“This is about everybody’s human rights,” says Titchener of single-sex provision. “There’s already been a High Court ruling that the gender you are born as is what you are going to be treated as under the Equality Act.

“I’m not standing against anybody who wants to identify as a female,” she goes on. “I can’t take that right away from them, but I equally can’t take the right of another individual from having protection and dignity. That’s a very fine line if you are allowing it to creep into the estate with no regulations around it.”

Related cases have been raised with her, she says, including that of a non-verbal mental health patient receiving treatment at home who was attended by a transgender caregiver, despite requesting only female staff. And there have been cases similar to that of Peggie’s raised too. “I have had so much,” she says. “There have been men identifying as women being in mental health wards, people working with somebody who’s now identifying as a female in their changing room. 

“We have to assess risk. If we do it on an individual basis, is that enough to protect the vulnerable patients who are there? Then, [for transgender people] are we damaging their mental health? Somebody has to make a decision, but for me that decision then has to safeguard vulnerable people. 

“What’s the risk management? If you are doing that then let’s see the evidence for that. We have to have that compromise for everybody.”

And, as Titchener reminds Holyrood, she is still adapting to the lay of the land. “What I’m realising is I’m not Scottish. I’m expecting people to say, ‘what would she know, she’s not from here’.” That’s partly down to difficult environments she’s entered in previous jobs. But every time, she’s ploughed on regardless. “This is still just about the fundamentals of patient care,” she says, “and how we are not listening to patients.”