Witness to Harm-Holding to Account. Improving patient, family and colleague experiences of Fitness to Practise proceedings: A mixed-methods study

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Improving patient, family and colleague experiences of Fitness to Practise proceedings: A mixed-methods study Health and Social Care Delivery Research, No. 13.44 Louise Wallace , Sara Ryan , Rosalind Searle , Gemma Hughes , Annie Sorbie , Gemma Ryan-Blackwell , Sharif Haider , and Richard West . Author Information and Affiliations Authors Louise Wallace , 1 ,* Sara Ryan , 2 Rosalind Searle , 3 Gemma Hughes , 4 Annie Sorbie , 5 Gemma Ryan-Blackwell , 1 Sharif Haider , 1 and Richard West 6 . Affiliations 1 Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK 2 Department of Social Care and Social Work, Manchester Metropolitan University, Manchester, UK 3 Adam Smith Business School, University of Glasgow, Glasgow, UK 4 School of Business, University of Leicester, Brookfield, Leicester, UK 5 University of Edinburgh School of Law, Old College, Edinburgh, UK 6 Public Contributor, UK * Corresponding author ; Email: [email protected] Southampton (UK): National Institute for Health and Care Research ; 2025 Dec . Copyright and Permissions Copyright © 2024 Wallace et al. This work was produced by Wallace et al . under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/ . For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited. Abstract Background: In the United Kingdom, over 2.5 million health and social care professionals are registered by 13 statutory professional regulators. When professional conduct falls below standard, registered professionals may face an investigation into matters such as their conduct, health or competence via fitness to practise processes. Very serious cases are heard in public by an independent adjudication panel. The public, the largest source of concerns, may be asked by the regulator to be cross-examined in a hearing where their evidence may be crucial. Witness cross-examination is known to be distressing in the criminal context, where the victim is questioned about the harm they experienced and how they faced the alleged perpetrator. In fitness to practise, retelling stories could be similarly retraumatising. Our research focuses on the public (and colleagues) who raise concerns, including that they have been harmed by a professional, and examines their experience of engaging with fitness to practise processes. Design and methods: The study employed multiple qualitative methods. Public website materials were analysed using thematic content analysis, accessibility and readability algorithms and a useability survey about submitting a complaint ( n = 11). The views of the public and those with personal experience of fitness to practise validated our analysis of the web content ( n = 15). Sociolegal analysis was conducted of the United Kingdom’s social work/social care regulators’ conceptualisations of witness vulnerability and special measures. Twenty-seven registrants’ employers were approached, and 25 were interviewed about organisational support for registrants, patients and service users. Data collection via regulators ( n = 285) with small numbers via social media included surveys, ( n = 64 in total) across 9 regulators, interviews ( n = 47) across 10 regulators, ethnographic observation of hearings ( n = 22) with 81 days of observation across 9 regulators, and documentary analysis of hearings determinations and witness statements across 13 regulators ( n = 207). Project recommendations were coproduced through six formative workshops involving public members, legal, health and social care professionals, regulatory staff and lawyers and academics. Analytic methods included institutional ethnography, thematic analysis and narrative portraits. Results: The website information for the public was often too much or too little, in inaccessible formats, and requiring high literacy and digital skills. The social care regulators’ conceptions of vulnerability largely relied on inherent factors (e.g. disability), or misconduct categories, rather than being situationally sensitive to witnesses’ diverse needs. The experience of those who had been harmed was found to be profoundly distressing for most participants at each stage of the fitness to practise process: having to retell their story, uncertainty about when and where they would need to respond, and taking part in a legalistic and adversarial process where their evidence, and credibility, were questioned. Findings informed 20 recommendations. Project resources are available for all stakeholders. Conclusions: This project provides globally unique evidence of the experiences of the public involved in health and care professional regulation. It recommends improvement of professional regulation through public-focused information, compassionate and trauma-informed communications and support, and for independent cross-regulator evaluation. Public and stakeholder involvement and engagement: Our research was informed throughout by people who had personal experience of fitness to practise, regulators, employers, lawyers and professional bodies. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR131322. Plain language summary This study is about how the public are involved in the regulation of health and social care professionals in the United Kingdom. Over 2 million professionals (e.g. doctors and social workers) are registered by law with their regulator. If their behaviour is substandard, they can be investigated. In the most serious cases, this might include a public hearing where a decision will be made about whether they can continue to practise. This process is called fitness to practise. We know the process is stressful for professionals. We wanted to find out how the process works for the public, who may be involved by raising a concern and by giving evidence at a hearing. We focused on people who may have been harmed by professionals, because little is known about their experiences of fitness to practise. We examined the information for the public on 13 regulators’ websites. We undertook a survey of people who had raised a concern, and we interviewed people who had been part of a hearing. We examined documents, including witness statements, legal documents and policies, and we observed hearings. We interviewed the public, lawyers and independent hearing panel members. We held four workshops to coproduce our recommendations with members of the public, regulators, health, social care, lawyers and academics. We found that most of the regulators’ websites presented too much or too little information, which was too complex, in inaccessible formats and made the process of navigating the website difficult. Members of the public who had been harmed and who raised a concern and took part in investigations and hearings mainly found the process to be onerous, protracted, distressing and disappointing. We found regulators and employers often did not offer enough support to the public. We produced recommendations and resources to improve these processes. Introduction The problem being addressed The overarching principle of professional regulation is to protect the public, including maintaining public confidence in the profession and/or upholding professional standards. When professional conduct falls below standard, registrants may face an investigation into matters such as their conduct or competence, and potentially, sanction via fitness to practise (FtP) processes. 1 It is understood that the process can be stressful for the registrant, 2 – 5 including being associated with the risk of suicide for those under investigation. 4 , 6 Research has focused on what can be done to improve the experience of registrants, with little known about the effect of participation in a FtP process on those who have witnessed the alleged misconduct namely, patients and service users, their families and colleagues. A striking research omission is the experiences of those who may have been harmed or bereaved and who are subsequently involved in FtP processes in relation to the conduct of a registrant or registrants. The focus of our research was to consider cases where the regulators’ responsibilities to the patient, service user, family or colleague witness are most tested, and whether and how the processes of FtP can create further harm, which can exacerbate the original harm when providing evidence in a FtP investigation and potentially at a public hearing. We considered regulators’ responsibilities to public witnesses to be to treat people fairly and respectfully, for example, keeping them up to date with the progress of their complaint, and to take reasonable steps to avoid their regulatory processes causing harm to witnesses. We were of the view that this could be conceptualised as part of the regulators’ overarching objective to protect the public. When developing this proposal, our review of FtP studies with regulators suggested that the greatest risks from adverse experience arise where the public witness has been directly, and lastingly, harmed by the registrant. 5 , 7 This project focuses on such cases in which direct and lasting harm can arise and which are likely to test fully the efforts of regulators to best balance their interest in maximising the engagement of these witnesses in the FtP process while minimising further additional harms from such engagement, for example, as defined in the Medical Act, Section (1A). 8 Professional regulation, the public and harm The piecemeal way in which the statutory regulation of health and social care professionals has developed in the UK over hundreds of years means that each of the regulators has a different legal and policy framework. However, despite these differences, similar provisions can be found in the governing legislation of the regulators. Although the precise wording may vary, the overarching objective of professional regulation is to protect the public. This overarching objective is underpinned by the pursuit of three key aims [to use the General Medical Council (GMC) as an example]: ‘(a) to protect, promote and maintain the health, safety and well-being of the public; (b) to promote and maintain public confidence in the medical profession; and (c) to promote and maintain proper professional standards and conduct for members of that profession’ [Medical Act, 1983 Section (1B)]. 8 This objective is discharged though the regulators’ work in a variety of areas, including setting standards for education, registration and practice. However, for the purposes of this project, we focused on the regulators’ role in investigating concerns about those on their respective registers and making decisions about whether they should be able to continue to practise without restrictions via their FtP processes. 9 Most professional regulators have no powers of inspection; instead, they are dependent on concerns from sources such as the public, registrants and employers or findings of other courts or regulatory bodies, which are brought to the attention of the regulator. The health and social care sectors employ the largest number of people in the UK. Within this sector, the Professional Standards Authority (PSA) is the meta-regulator that has oversight of 10 statutory regulators covering 33 professions. The statutory regulators within the ambit of the PSA regulated 1,830,638 registrants at March 2023. 10 There are three further statutory regulators of social workers/social care professionals for Scotland, Wales and Northern Ireland, with together around a million registrants in March 2024. 11 – 13 In March 2023, the 24 accredited registers regulated 104,000 professionals. 10 In early 2024, there were 29 accredited registers under the PSA . The accredited registers differ from statutory regulation, as the registration of the professionals is not compulsory. Thousands of concerns about the professionals’ practice are referred each year to regulators, but these referrals are a small proportion of those on their respective registers. For example, in 2022–3, the Nursing and Midwifery Council (NMC), which holds the largest register, had 788,638 registrants. In 2022–3, 25,068 concerns were raised with the NMC (3.1% of registrants). In that year, 76% were closed without investigation and 533 went to a hearing. 14 By contrast, in the same year, the Pharmaceutical Society of Northern Ireland (PSNI) had 2893 registrants, received 128 concerns, 11 were investigated and 2 went to a hearing. 15 The public are often the largest source of concerns, though they are less likely than other sources (e.g. employers and police) to progress to a hearing. 13 The public may provide crucial factual evidence to help regulators and their FtP committees to understand what has happened when a concern is raised about a professional’s behaviour. As we have suggested above, attending to the public’s (and harmed colleagues’) perspectives is relevant to the overarching regulatory objective to protect the public. 16 The FtP process varies between regulators, but it has distinct stages that can be identified despite variations in legal and policy frameworks. These stages include raising a concern to the regulator, initial investigation and decision-making as to whether the case is sufficiently serious to proceed to a hearing for adjudication, or some other form of resolution. The regulator will decide whether those involved need to become witnesses and provide evidence, either in writing or in person. In some circumstances, such as where this evidence is disputed, an independent FtP panel (also known as a tribunal or a committee) may need to convene to decide whether a registrant’s FtP is impaired. In doing so, the evidence of a witness may be scrutinised through cross-examination; this can be a daunting procedure. 3 – 5 Over the years, there have been different tests that have set out when a professional regulator can take action in relation to the practice of a registrant. However, following concerns about the ways in which regulatory processes had failed to meet the expectations of patients and public (in the wake of the inquiry into the conduct of the doctor, Harold Shipman, 17 who was convicted of the murder of 15 patients), most (but not all) of the regulators use the terminology of ‘impairment of FtP ’. The specified grounds on which impairment can be established are set out in legislation and include matters, such as misconduct, deficient professional performance, health and conviction or caution, among others. Case law has established that the emphasis of this test is on current impairment. 18 Further, ‘… the purpose of FTP proceedings is not to punish the practitioner for past misdoings but to protect the public against the acts and omissions of those who are not fit to practise. The [panel] thus looks forward not back. However, in order to form a view as to the fitness of a person to practise today, it is evident that it will have to take account of the way in which the person concerned has acted or failed to act in the past’. 19 Hearing outcomes vary between regulators but can range from no order to limitations on practice or removal from the register (sometimes called ‘striking off’). There are no provisions for apology or recompense. The PSA defines harm as ‘physical injury or psychological distress experienced by people through interaction with health or social care practitioners’. 20 They further acknowledge differing definitions and categorisations of allegations of misconduct from regulators, stemming, in part, from their differing standards of professional conduct. 21 Our project focused on cases where witnesses have suffered harm and there are relevant allegations that a registrant’s FtP is impaired. We note that some harm can occur during care without reaching the threshold of impairment, or investigation may reveal that the conduct may not be attributable to the registrant under investigation, for example, due to systemic issues beyond the registrant’s control. Regulators use a range of measures designed to support witnesses. These include providing: information about the FtP process and hearings; virtual tours of FtP hearing rooms; a single caseworker point of contact; and, for specific cases, special adjustments may be made, such as using screens (in an in-person hearing) or turning off cameras (in an online hearing), to protect the witnesses under cross-examination from the registrant’s sight (often known as ‘special measures’). Experience from criminal justice systems, however, suggests legally available adjustments often fail to be made because needs are not identified. 22 – 24 Patient and public expectations of regulation Patient safety regulatory healthcare oversight in England is provided by over 126 bodies as well as NHS commissioners. 25 There can be multiple bodies involved alongside professional regulators where patient safety is a concern. Research has mapped NHS patient safety regulation, including professional regulation. 25 The resultant complexity of these different and concurrent investigations can require a witness to recall their experiences multiple times over protracted time periods. The impact on the witness of these concurrent processes while involved in FtP processes has not been explored to date. Dutch Healthcare Inspectorate research on complaints by individuals to healthcare regulators reveals that service user/patient and family experiences are given lower credence in an implicit hierarchy of evidence, below that of clinical records. 26 Yet, evidence shows that the patients’ views of their experience of professionals in the UK contain more than just clinical concerns. 27 – 31 For example, patients may give evidence in relation to interpersonal matters, such as the breach of professional boundaries, which they have experienced as harmful, but which may not be evidenced in a clinical record. So, for some people, there is a disconnect between their expectations and experiences of engaging with regulatory processes. Research on patient and family concerns about professionals when things go wrong Research on adverse events shows that healthcare staff often have little understanding of the experiences of those who have been directly harmed and of their exacerbation by the investigatory process itself. 32 Research exploring NHS complaints 33 and litigation 34 has revealed that patients who complain, or make a legal claim, cite a wide range of factors in their decision to take this action, including: the desire for an apology, to avoid similar incidents happening to others, to hold key individuals accountable and/or for financial compensation. Similarly, families involved in patient safety investigations were found to have wide-ranging needs and reported physical, financial and/or emotional vulnerability, sometimes exacerbated by inadequate investigation processes. 35 Much less is known about why people refer concerns to a regulator. Research commissioned by a regulator reported a range of expectations, including punishment and redress, which lie outside regulators’ jurisdiction. 36 A study of 25 people who had been part of a FtP process before 2011 found that participants were confused about the different channels for complaints and their distinct purposes. Further, they reported the process to be prolonged and taxing, with a mismatch between their initial expectations of the process and the final experience. 37 A realist review conducted for the General Dental Council (GDC) was focused primarily on registrants and regulatory professionals, with a small number of public informants (interviews were conducted with two public witnesses), and made several recommendations for improvements in FtP processes. 5 A survey of 1217 ‘notifiers’ (complainants) and 1604 registrants to the Australian multiprofessional regulator found the process to be frustratingly long, that those who raised concerns were not kept updated and that the process lacked transparency and impartiality. 7 Research on the public’s experience of fitness to practise A study conducted in 2012–3 of the experience of the public in the FtP journey, and at GMC hearings, recommended various improvements to communications. The study highlighted the evidence gap of public witnesses’ experiences of hearings. 38 A long research tradition exists on the role and experiences of witnesses in criminal trials. This includes the experience of different types of witnesses, including experts and lay witnesses, as well as the extent to which witness participation is facilitated or restricted due to structural or other reasons, and the potential for traumatisation and secondary victimisation. 24 We see that there are analogies here to be drawn between the criminal and FtP contexts, for example, in relation to the literature on vulnerable witnesses, 39 , 40 but there are also differences that we interrogate; for example, there are key structural differences in relation to both the procedural rules that govern FtP and criminal proceedings. Further, these proceedings have different purposes: while criminal proceedings are punitive, FtP proceedings are (primarily) aimed at protecting the public. 41 The adversarial approach to cross-examination in FtP hearings can be particularly distressing in cases of serious harm. Exploration by the Health and Care Professions Council (HCPC) of the determinations (outcomes) of sexual abuse cases against social workers describes the intrusive testing of victims’ truthfulness as a witness, the lack of apology or remorse shown by registrants and the regulator’s failure to protect witnesses from harm. This research questioned the low rates of special measures applied to support these victims and unfavourably compared the level of support with that provided in the criminal justice system. 42 The professional duty of candour includes, where relevant, a professional making an apology where things have gone wrong. A study commissioned by the PSA found that little is known about public’s responses to this in the context of FtP hearings. 43 Yet, studies of post-traumatic stress disorder following trauma highlight the importance of these processes in promoting a ‘coming to terms’ and the forgiveness of the perpetrator to achieve post-traumatic growth. 44 Staff concerns about colleagues’ misconduct Some behaviours towards colleagues that may amount to impairment of a registrant’s FtP are likely to be intentional. For example, staff bullying in the NHS is found to be a frequent and persistent problem affecting 18% of staff in 2023, 45 and in earlier research, between 10% and 16% of junior doctors reporting bullying. 46 The consequences of bullying for colleagues and bystanders can include serious and lasting physical and psychological harm. Study of sexual misconduct occurrences in the NHS leading to FtP adjudication revealed that they occurred in contexts that also had wider bullying and harassment climates 6 and could be prevented by employers. A recent survey about sexual misconduct by surgeons shows low confidence of the surgical workforce in NHS organisations’ processes for handling sexual misconduct, and those of the GMC , with 90% of the participating women surgeons witnessing sexual misconduct compared to 81% of men, while 63% of women compared to 24% of men had been a target of this behaviour. 47 Our research examines the perspectives of colleague witnesses, who have been harmed by coworkers, of the FtP processes. Our employer-focused outputs are intended to complement policies of candour, antibullying and speaking up. Rationale for the study and regulatory context The research addresses a gap in knowledge about the experiences of the public in engaging with FtP , particularly when they have experienced harm by the registrant. While there are implicit assumptions about the cathartic effect of public inquiries, NHS investigations and FtP processes, 48 there is little recognition that such experiences may add to people’s distress. In recognition of the evidence from research on the retraumatising effects of being a witness in court for vulnerable witnesses in the criminal justice system, there is a framework for trauma-informed practice across public services in Scotland. 49 Further, bereavement research shows how the suffering following a traumatic death can be aggravated through revisiting the memories of events and the death over a prolonged period, either through rumination or discussion prompted by others. 50 There has been little consideration of the distinct, but also aggravating, impacts of FtP processes on those grieving. Engagement of key stakeholders Throughout development of the proposal and the research, we have been informed by all the statutory UK health and social care professional regulators and the PSA , employers, FtP lawyers, trade unions and members of the public with lived experience and representative bodies. Their input has been vital at all stages of the research and our ongoing work on dissemination and impact. See Report Supplementary Material 1 . Aims, objectives and research questions Aims Our mixed-methods study focused on cases of alleged serious misconduct, that involved harm to others, to increase awareness and improve understanding of the expectations and experiences of the public involved in FtP proceedings, identify improvements to the processes to minimise the secondary harm that can arise to witnesses and to improve public trust in regulation and the professions. Objectives Examine the experiences of patient/family/and colleague witnesses in the different stages of FtP processes, including: initial contact; engagement; other complaint/investigations related to their contact with the registrant and services involved; the hearing stage; cross-examination processes; the outcome/sanction; and their responses to admissions and expressions of apology, or regret by the registrant. Conduct a systematic analysis of the content and user experience of existing FtP information, resources and interventions for witnesses. Identify where and how these processes and interventions could be improved to benefit complainants and witnesses and improve the efficiency of regulation. Codevelop and coproduce ‘good practice’ guidance and resources for a range of stakeholders, namely the public, regulators, health and social care employers and regulated practitioners. Research questions RQ 1. What are the experiences, support and information needs of patient/family/colleague witnesses involved in different stages of FtP processes of the professional regulators’ FtP investigations and hearings in the UK? (objective 1) RQ 2. What factors influence these witnesses’ view of the outcome of pre-hearing disposal decisions and hearings, including their view of the registrant’s admissions, the weight given to their testimony, expressions of apology or regret by the registrant? (objective 1) RQ 3. How accessible are witness support offers (information, staff and independent witness support/victim support and adjustments to FtP processes by regulators), how are they experienced and how might these be improved? (objectives 2 and 3) RQ 4. What are the experiences of health and social care employers of the support needs of witnesses, including the decision to refer, and throughout FtP investigations and hearings? (objective 3) RQ 5. What is the experience of lawyers for the registrant and for the regulator of the support needs of witnesses and the approach to fair witness testimony and cross-examination in hearings? (objective 3) RQ 6. What are the key legal and regulatory frameworks which impact on how witness vulnerability is understood and responded to in FtP proceedings in the context of the regulation of social work and social care professionals in the four countries of the UK, and how might these be improved? Methods for data collection and analysis The study was conducted in work packages (WPs). WP1 focused on the public experience when raising a concern, public information about the FtP process, the views of the public about this information and the support offered to the public by regulators and health and care providers. A review of social care regulators’ websites was undertaken to examine constructions of witness vulnerability (with add-on funding). The research also included those who experienced witness support services of some regulators. The focus of WP2 was on cases where there had been a public witness who had alleged harm to themselves or their family or as a colleague, as well as lawyers, panel members and regulator employees involved in these cases where there had been a hearing before a regulators’ independent panel. These WPs also involved participants recruited via the survey and social media. Nine regulators signed data-sharing agreements to enable participant recruitment ( Figure 1 ). FIGURE 1 Overview of the project. The study was informed throughout by three advisory groups: (1) Public Advisory Group (PAG) included public and patient members, public advisory and advocacy bodies; (2) regulators, including the PSA ; and (3) professional associations, lawyers and employers. The Study Steering Committee membership included academic and practice experts in regulation and people with lived experience of FtP and/or of health and care services (see Report Supplementary Material 1 ). Recruitment procedures and data sources Participants for the survey were recruited via seven regulators, who identified cases closed in the past 6 months where the complainant alleged harm and via social media and sent them the research information and contact details of the researcher. Participants in interviews for analyses of websites were members of two regulators’ PAGs, and people with personal experience of FtP contacted through the charity Action against Medical Accidents (AvMA). Live cases (hearings held in public in person or online) were observed by researchers in the same capacity as members of the public. Suitable cases were identified directly by researchers by reviewing notices of hearings and allegations and in discussion with regulators who were asked to identify hearings likely to involve harmed public witnesses. The regulators identified the harm cases for interviews from their case management systems. The regulators required that cases be closed and out of time for appeal before research participants could be recruited. An invitation to take part in this research, along with contact details of the research team, were sent by regulators. Participants then contacted the researchers who supplied further information about the project and a consent form for them to complete. WP2.1 recruitment is shown in Figure 2 . FIGURE 2 Recruitment for WP2.1. For all WPs, participants contacted via social media or recruitment by the membership of the AvMA newsletter were given the contact details of a researcher, who provided information and completed consent. In doing so, they ascertained if the person was eligible, that is had taken part in FtP proceedings at a relevant stage, and alleged harm by the registrant. Their FtP cases could have been at any stage with any of the regulators, including those not closed. Employer participants were recruited via the team’s contacts, including from prior research ( NIHR 129491), using snowballing. 51 Documentary sources were obtained from the regulators and the websites of all 13 UK statutory health and social care professional regulators and two tribunal services. When considering text relating to witness vulnerability and special measures, we considered the legal and policy frameworks of the regulators of social care and/or social work professionals, including their respective legislation and guidance on this issue. For completed cases in WP2.1, 3788 determination documents were obtained from regulators’ websites. Twenty-one witness statements and determinations were obtained from the regulator and from witnesses. Documents pertaining to cases (allegations, notices and determinations) were collated from regulators’ websites, and the interviewees provided with additional documents to supplement interviews. See Appendix 1 for the recruitment of participants, cases and determinations. Work package 3 consisted of three analysis workshops, where the team addressed the research questions in their data and findings across WPs and developed summary material to present in co-design 52 workshops. Work package 4 consisted of six formative co-design workshops 52 of up to 4 hours (two online, two hybrid) between October and December 2023. These were to develop actionable recommendations and the focus of public resources. The first workshop focused on public and people with lived experience of FtP as participants; the following three workshops involved advisory group members and other invitees, including National Institute for Health and Care Research (NIHR) researchers on related projects (e.g. of healthcare complaints). The format comprised a project summary and infographic (see Report Supplementary Material 2 ) sent in advance of each workshop. Short presentations about emerging findings included, for example, ‘witness work’, ‘trust’, ‘vulnerability’ and then small group work to address provocations about these areas. Briefing summaries of the workshop discussions linked the research findings to the workshop discussion, raising further issues for consideration and drawing out key points to inform the recommendations. A graphic illustration of each workshop was also produced. See Report Supplementary Material 3 for an example output. Careful attention was paid to the hybrid process to ensure that online participants could contribute. See Report Supplementary Material 4 for WP4 coproduction attendee analysis. Two further coproduction workshops of up to 1.5 hours were held online with the four regulators of social care and/or social work professionals in relation to their legal and policy frameworks on witness vulnerability and special measures. Analysis methods The WP1.1 and WP1.3 used descriptive data and thematic content analysis. WP1.2 used qualitative media analysis 54 and content analysis, 53 Flesch Kincaid Reading Ease, Flesch Kincaid Grade Level, Gunning Fog Score, Simple Measure of Gobbledygook Index, Coleman Liau Index and Automated Readability Index algorithms were used for readability. 56 – 58 Accessibility was assessed by applying an algorithm ( www.accessibilitychecker.org ) to the whole website. Website navigability used an adapted System Usability Survey. 59 WP1.4 employer interviews were analysed using template analysis. 60 As part of our add-on funding, focused on social care, we explored the relationship between social work, social care and witness vulnerability (as set out in legal and policy frameworks) using a sociolegal approach to our desk-based research, which can be understood as ‘a way of seeing, of recognising the mutually constitutive relationship between law and society’ (Creutzfeldt et al . 2019, p. 4). 61 In WP2.1, the 3788 determinations were reviewed, and 207 cases were identified as including harms. First, these retained cases were coded using an a priori coding system adapted from previous research 62 to include: characteristics of the registrant and witnesses, event background information, witness event response, elements pertaining to vulnerability surrounding the misconduct and regulator FtP processes and outcomes. Second, interviews included memory reconstruction techniques 63 to produce event maps 64 and timelines 65 and solution-focused techniques 66 to manage a potentially distressing interview. Analysis of all sources used initial deductive ‘first-order’ coding, and then data were thematically grouped around inductive ‘second-order themes’. 67 Work package 2.2 used institutional ethnography to trace relations between witnesses and institutions, resulting in indexed interview transcripts and narrative summaries of each hearing. 68 , 69 The interviews in WP2.3 were analysed drawing on narrative portrait 70 and thematic approaches. 67 Data analysis of WP1.1, WP2.1, WP2.2 and WP2.3 includes: (1) modified grounded theory; 71 (2) case narratives and (3) combined descriptions of the communicative genres, events and practices that were observed. 72 The briefing documents from each workshop acted as formative summaries, leading to the development of draft project recommendations. These were shared among team members and advisory group members by e-mail for comment in a process that led to several iterations. Reaching a consensus was challenging among the varied stakeholders, and the introductory paragraph was produced to make it clear that team members and project contributors were conflicted in making recommendations around improving a process that was not perceived by some as fit for purpose. Findings’ summary Participants and documents Response rates for participants where known, source of recruitment, numbers by WPs and regulator are presented in Appendix 1 , Tables 1 and 2 . Appendix 1 , Table 3 gives the data on retrospective cases analysed from determinations and other documents. See published papers for documentary analysis data. 73 – 77 Work package 1.1 Some 285 harmed public referrers were approached by the regulators, of whom 60 were recruited (21.05% uptake) and 4 public referrers were recruited from social media across 9 regulators. For WP1.3, 2 regulators provided invitations to their public panels (circa 20 people) and 7 took part, and 6 were recruited for interviews via the AvMA . For WP1.4, 27 employers were contacted, and 25 employers were interviewed about 11 regulators. Work package 1.5 Two regulators agreed to recruit participants who used their in-house regulator support services. However, most of these were judged by the regulator to be too vulnerable to participate, and of those approached, none agreed to take part. Work package 2.1 A total of 131 invitations to participate in an interview were sent by regulators; 11 (WP1.1) survey participants were contacted for interviews, leading to a final 21 interviews. Work package 2.2 Twenty-two FtP hearings were observed of nine regulators, giving 81 days of observation. Observations were supplemented by 56 documents; 36 people were invited for interview by regulators and 6 accepted. A further four responded to requests for interview for WP2.2. via social media and two from the WP1.1 survey. Work package 2.3 Fourteen people were recruited for 11 interviews: 4 from regulators, others from social media and the AvMA . Summary of findings by research question: RQ1: What are the experiences, support and information needs of patient/family/colleague witnesses involved in different stages of FtP processes of the professional regulators’ FtP investigations and hearings in the UK? (objective 1) Of 64 survey participants whose case was closed early, 54 were disappointed/very disappointed, and two cases were ongoing. Harm was defined more broadly than by regulators and included rights harms. Participants in WP2 were left dissatisfied with why their case had not progressed if it was disposed of pre-hearing. Interviews with the public witnesses at a hearing felt that the interests of the professional were being placed above those of service users/patients. Their experiences of FtP often resulted in their causes for concern not forming the basis of the FtP investigation and/or hearing. They concluded that their legitimate concerns were thus not important to the regulator. Given the purpose of FtP described above, this reflects a mismatch of expectations and what regulators are required to do to bring a FtP case. Additionally, their experiences of the conduct of the hearing process itself left them feeling that little weight was given to their testimony or concerns, often due to registrants’ representatives’ adversarial cross-examination. The impact of the incident on them was not shared. In effect, there was ‘disposal’ (in the general rather than legal sense) of their testimony and the resulting perception that their perspective and concerns were being disrespected. 78 We found that most witnesses experienced FtP as being onerous, difficult and disappointing in terms of outcomes and processes. For some witnesses, engagement in FtP was potentially retraumatising. We found that these experiences arose due to: the nature of the work that was required by witnesses and the processes of gathering and testing evidence, which were compounded by previous experiences relating to the reasons for raising a concern and expectations of the institutions involved. Witnesses had to undertake onerous work (expending their time, energy and resources) to: raise concerns, give evidence, attend hearings (online or in person), undergo cross-examination and to make sense of the outcomes of hearings. The processes of gathering and testing witnesses’ evidence resulted in experiences of epistemic injustice 79 , 80 when witnesses’ accounts of events and credibility in interpreting and recalling those events were subject to scrutiny and cross-examination. Providing and being questioned on evidence that related to traumatic and harmful events appeared to be distressing for some witnesses, and these processes made them vulnerable in the sense of being made open to further social and emotional harm and potential retraumatisation. Adversarial cross-examination was particularly difficult. Witnesses’ expectations of and motivations for participating in FtP (such as hoping to understand events and to prevent similar events happening to others) were often at odds with regulators who were necessarily focused on registrants’ actions rather than the impact of events on witnesses. Witnesses often came to FtP after having undergone other complaints processes and investigations. They had certain expectations of regulators related to expectations more broadly of the health and social care system and were disappointed with how they were treated. Collectively, these experiences have the potential to undermine public trust in regulators and regulatory processes. In WP2.1 and WP2.3, following the hearing, participants said the communication by the regulator’s staff was limited and impersonal. Of the witnesses we interviewed, few had used the regulators’ outsourced witness support offerings (Victim Support), and those that did were dissatisfied. Overall, in WP2, participants reported experiencing very poor communications from regulator staff, often adding to the original trauma. RQ2: What factors influence these witnesses’ view of the outcome of pre-hearing disposal decisions and hearings, including their view of the registrant’s admissions, the weight given to their testimony, expressions of apology or regret by the registrant? (objective 1) The WP2.1 retrospective interview responses showed that witnesses often felt disposed of in the regulators’ processes, with little proactive communication about their case during the long periods with no contact prior to a hearing. Then, they were expected to give evidence within the system and were not allowed to tell their own story, and critically, its impact and ongoing consequences. Views of participants varied, with some wanting an apology, others not. What participants shared was dissatisfaction with how such apologies were given. For example, in WP2.3, two participants felt that saying sorry was key (although it is not a requirement of FtP) and expressed incredulity at how hard it seemed for people to apologise. One participant was horrified that the registrant was allowed to say sorry to him during the hearing, while some others felt any apology made was ‘empty’ and unconvincing. Further, apology can apply to the regulator, as one participant said it took 56 e-mail exchanges with the regulator before someone said they were sorry her baby died (again, not a requirement of the regulator, but a matter of respect). RQ3: How accessible are the witness support offers (information, staff and independent witness support/victim support and adjustments to FtP processes by regulators), how are they experienced and how might these be improved? (objectives 2 and 3) Regulator website content was found to broadly address all stages of FtP but with great variation in volume at each stage and between regulators (WP1.2). There were some examples of flow charts and formats such as videos which were welcomed by focus group and interview members (WP1.3). 73 Readability results showed that most documents would require at least school age reading of 14- to 16-year-olds’ complexity, and most required a higher level of reading ability. 74 Only 4/17 websites were compliant with the government’s accessibility criteria. Website usability to enable the creation and submission of a concern was below the norm for all but two regulators. 75 Improvements are recommended, including the coproduction of information with the public. We were unable to recruit the people who were identified by the two regulators with in-house witness support services, who had used these services. During the study, four regulators offered an external support service (Victim Support). Few interviewees from WP2 expressed opinions about these external support services. Two interviewees were aware it was available but felt that lack of information about the progress of the hearing was more important than emotional support. In the narrative interviews (WP2.3), there was some discussion about support. One participant, for example, received support from a new witness contact role introduced by the regulator. This experience was positive in terms of the witness feeling less isolated and having someone to contact for updates; however, this did not ameliorate the harm the participant experienced as a witness in the process. RQ4: What are the experiences of health and social care employers of the support needs of witnesses, including the decision to refer, and throughout FtP investigations and hearings? (objective 3) In WP1.4, we found that employers offered similar information and well-being support to registrants as they would during a local investigation such as occupational health, line manager support and staff counselling service. The eight senior staff who had prior experience of being a witness in FtP were more willing to give in-person support to registrants while attending a hearing. This was in stark contrast to the support offered to most patients and service users attending FtP hearings, which comprised that offered routinely to those going through local complaint procedures. One employer, who offered the equivalent support for both staff and service users, did so in the context of having a long-term relationship with their service user and worked to rebuild trust in their service. 76 Employers found their interactions with regulators sporadic and demanding. This was less so where a regulator had a named point of contact with whom they could seek advice about potential concerns and to keep them updated. 81 In WP2.1, some interviews with harmed colleague witnesses found that employers gave varying support for their staff members. Further, they revealed concerns about having to come back to work alongside those about whom they had raised concerns. RQ5: What is the experience of lawyers for the registrant and for the regulator of the support needs of witnesses and the approach to fair witness testimony and cross-examination in hearings? (objective 3) In WP2.1, interviews included those with two lawyers who considered the impact of the FtP process and hearing on the witness. They reflected on the potential tension between explaining the process to witnesses and providing support, while always making sure not to lead the witnesses in the statement taking process, to ensure that they were giving their own, independent evidence. Lawyers were very aware of the line between witness familiarisation (which is permitted in the UK) and witness coaching (which is not). There was also concern about the circumstances in which regulators compel witnesses to be part of the hearing process. Lawyers said the power was seldom, if ever, used with members of the public. This contrasts with the views expressed by some participants who felt they were (though were not actually) compelled to be a witness. RQ6: What are the key legal and regulatory frameworks which impact on how witness vulnerability is understood and responded to in FtP proceedings in the context of the regulation of social work and social care professionals in the four countries of the UK, and how might these be improved? We found that textual constructions of witness vulnerability in the social work and social care professional regulators’ legal and policy frameworks could be, at the same time, too narrow, too broad and potentially stigmatising and further sit uncomfortably with a social model of disability. We call for a more holistic textual approach to how witness vulnerability is framed and make suggestions about how this may be operationalised in policy and law. Our findings have wider application, beyond the regulation of the UK-wide social work and social care workforce, where regulatory processes designed to protect the public rely on witnesses coming forward to provide evidence. 77 See Appendix 2 for publications, conferences and other outputs and resources. Discussion Principal findings and achievements per project outcome, contributions to knowledge, strengths and weaknesses This study found that the FtP process is experienced as inherently unjust by public referrers and is not designed to engage them as lay people for whom this will be a new process. Information is overly complex, legalistic and often in inaccessible formats on websites which are difficult to navigate. It is apparent the public are not the prime intended audience of much of the material. While the focus of FtP is the registrants’ conduct, its main purpose is to protect the public. This does not translate into a focus on protecting the public as participants in the FtP process. People who raise concerns expect to be kept informed and managed with courtesy and compassion. We make many recommendations that are like those in the proposed ‘Harmed Patients Pathway’ for NHS trusts, which in commitment 5 also refers to the need to support patients who pursue FtP . 82 As our first recommendation points out, the systems for supporting the public through service providers’ and regulators’ processes have been found to be inadequate since 2009, 83 and we recommend that the changes required still apply. The organisational duty of candour applies to the registrant’s employer, and the professional duty of candour may form part of the regulators’ standards. 84 Both include giving explanations and apologies and are only indirectly concerned with rectification and improvement. For decades, frameworks in England (with broadly similar processes in devolved nations) have been introduced for local accountability and improvement and support various ways for patients and the public to engage. 85 While regulators are directly concerned with a registrant’s past behaviour and the risks of future behaviour, professional regulators also refer to ‘upstream’ activities to prevent the recurrence of the circumstances leading to misconduct or ill health, that is, sharing the learning from one or more similar cases. 86 , 87 The evidence of our participants, however, is that the local investigation and resolution are not always seen as adequate. Nor do any of these systems adequately address intraorganisational or system issues; for example, where recruitment processes fail to take account of the risks posed by a registrant because the employer or employing agency does not alert future employers to the registrant’s past behaviour, which may not have been referred to a regulator, or when the regulator’s investigation may have been hampered by inadequate evidence from the employer. We conclude that previous aspirations for safer systems that better engage the public are not being met. Our analysis highlights how the process was protracted, involving considerable practical and emotional ‘work’ for public referrers. Once referred, the ‘case’ was no longer theirs, and they could find their concerns were not addressed by the subsequent investigation and hearing. This loss of agency was unexpected and disappointing. They also experienced feeling unclear on when and how they would be involved, some experiencing abrupt requests for information at short notice, and at times, being required to repeat their story to different people at different stages of the process. We focused on people who alleged that they or their family experienced harm because of the behaviour of a registered professional. We found this was conceived of, but not formally defined by, regulators in different ways according to the conduct required by the professional standards, such as undertaking diagnoses and treatments correctly, and obtaining informed consent. This was narrower than the harms described by our participants who also included rights-based harms, such as failures to safeguard or protect their rights to make choices about care. They also reported the harms associated with taking part in the FtP processes, attributed to having to retell their story numerous times, being cross-examined and having their credibility questioned, distrusting the scope and validity of investigations and having to face questioning by the registrant or their representative. The study took account of how the impact of the initial harm event could be compounded by the FtP process. The initial event that generates or leads to the concern being raised is a potential breach of trust between a health and social care professional and the witness. The experiences of the FtP processes can exacerbate mistrust. 88 Trust may be undermined in the regulator as an institution, in regulators’ staff (including members of the independent FtP panel) and in their processes in terms of their competence, eroding the rational basis for reporting. 89 Further, the failure to respect and care for witnesses, both public and colleagues, can also undermine trust in regulators. More critically, as well as trust being eroded by these subsequent reporting experiences, these events can lead to the development of distrust, 90 in which the intentions and actions of the registrant are regarded as malevolent; regulation is viewed as protecting the profession and not the public. These experiences of eroded trust and distrust are indicative of low psychological safety, which is central to raising concerns. 91 Three kinds of experiences emerged from our interviews with those who had attended hearings: survival, recovery and thriving. 92 The research team were able to gain valuable insights from legal participants regarding witness preparation for and experience of cross-examination, speaking to RQ5. They commented that better guidance could be provided to witnesses regarding what can and cannot happen within the FtP process and concerning who may ask them questions during a hearing. Improving this aspect of preparation for witnesses can be achieved with greater transparency. Personalised communication with witnesses to identify issues such as vulnerabilities was also raised – with participants noting that this could come in conjunction with improved training for lawyers involved in the process. Furthermore, legally qualified participants indicated that, when appointed to conduct cases on behalf of the regulator, the role of legal firms’ employees in the FtP process could be enhanced to improve communication with witnesses, such as keeping witnesses up to date with the process and explaining the FtP process. Our analysis suggests that the cross-examination process can be a novel and intimidating experience for witnesses, and to reflect this, legal professionals involved in hearings could moderate their style of questioning to those who have experienced trauma to reflect trauma-informed practice. 49 It was also observed by legal participants that the approach of chairs of the FtP tribunal may be improved to be more neutral, as they may, at some points, become adversarial towards witnesses – which from the perspective of a witness may seem as though the chairs are themselves acting for the registrant, especially if the registrant is unrepresented. Participants, including public members and legal professionals, reflected on some of the challenges associated with COVID-19 and the subsequent move to predominantly online hearings. Participants commented on the use of multiple screens to facilitate an online hearing or hybrid hearing, where a witness may be online at an in-person hearing, or where it is to be offered online, as special measures for a vulnerable witness. This may sometimes result in a loss of detail regarding how the witness is experiencing the hearing; for example, visual cues such as the witness crying, posture or hand gestures in contrast with an in-person hearing, wherein the witness could be monitored more accurately and closely. For public witnesses giving evidence online, it was observed that although they may not have to travel to a hearing, it still required them to do certain work to connect, find a quiet private space, manage the software and to deal with issues of anonymisation (e.g. how their name was displayed on their screen to others in the public hearing). The support offered by regulators varied from nothing to support provided to a few ‘vulnerable’ witnesses before, during and after a hearing by a dedicated staff member or team in a small number of regulators. Although external support from Victim Support was contracted with four of the regulators during the project, we found little uptake. Our review of the social care/social work regulators’ institutional frameworks in relation to witness vulnerability indicated that textual constructions of witness vulnerability in the social work and social care regulators’ legal and policy frameworks could be, at the same time, too narrow, too broad and potentially stigmatising and may not accord with a social model of disability. Our findings have wider application across the regulation of professions in health care and across professions with public contact, such as teachers, lawyers and accountants, where regulatory processes designed to protect the public rely on witnesses coming forward to provide evidence. 77 As explored in WP1.4, employers can be a source of support for registrants (whether the subject of referral or a colleague witness), particularly so if they, as employees, have experience of being a witness in a FtP hearing themselves, which they found to be ‘daunting’ and ‘terrifying’. But very few offered any such support to patients or service users during FtP . This has implications for how regulators work to ensure ‘upstream’ information, and support from health and care providers complements that available from the regulator. Participants explained that, as employees in service providers, they conduct their role in relation to FtP alongside other duties, so it is unsurprising that they admitted their shortcomings and reliance on the regulators. 76 Our coproduction workshops (WP4), with input from members of all three advisory groups and other stakeholders, and feedback from the two dissemination events (see Report Supplementary Material 5 ), involved tensions and very different viewpoints among participants. These were openly discussed (with follow-up after the workshop, where appropriate), logged in briefing summaries and returned to in ensuing workshops, enabling us to formulate recommendations for all parties, for research and informed our public resources. For example, a debate about witness disrespect led to recommendations about compassionate communications; that about distress and traumatisation led to recommendations about trauma-informed practices (see Report Supplementary Material 3 ). This study’s strength is that it is the first independent multiregulator study to explore the experience and expectations of taking part in the FtP processes by the public in the world. The study contributes to improved public protection and evidenced-based FtP process improvement across all regulators. The study’s main weakness is that data collection was, in part, constrained by requiring recruitment via regulators (see Challenges faced and limitations ). Contribution to existing literature Some of the findings echo those from the GDC ’s realist review. 5 Their recommendations are not specific to the public, but note the adverse experiences for all types of witnesses, the lack of support and negative experiences of cross-examination. They recommend the GDC to ‘Enhance the accessibility of information provided to patients, the public and registrants about FtP , including by simplifying technical language and reducing text-heavy content’ (p. 82) 5 . Our research extends this by finding that the content, readability, accessibility and usability of the regulators’ web offer should be radically revised in relation to the public, using the tools available to this study and coproduced with the public. 73 – 75 The GDC report also recommends enhancing support for all FtP participants, and they advise ‘Enhanced training for FtP colleagues pertaining to empathy and identifying mental health risks’ (p. 82). Research in Australia also supports our recommendations for improved communications with all witnesses. 93 Our study goes further by emphasising the need for public-focused communications using trauma-informed practices and for the public to be treated with dignity and respect, valuing the contribution they make, largely through altruism, to the FtP processes. We also add a new perspective by elaborating how the public are put at an inherent disadvantage by regulators during the FtP process, which we consider to be a form of iatrogenic injustice, 94 with serious implications for public trust (see Recommendations for policy and practice). From the findings of a study of complaints to two Northern Ireland heath boards ( NIHR 127367), Rhys et al . recommended that resolving complainants’ unmet expectations requires relational congruence, person-centeredness and affiliative interactions, which echo our findings. 95 They found that people making complaints should be listened to when they tell their story and how it impacted upon them, to be treated as reasonable in making the complaint and for their complaint to be taken seriously. Our study similarly found the importance to public referrers of being listened to. Further, we found the hearing allegations often did not reflect their concerns. Rhys’s study found that insincere apologies were viewed negatively and that the acceptance of responsibility and recognition of the impact of the event was viewed positively. While the purpose of FtP is not to give redress to the person who raised the concern, we found that verbal and written communications with them did not acknowledge the impact of the event, rather focusing on how the process achieved the aims of the FtP process by focusing on the outcome for the registrant. Rhys et al . 95 noted that poorly received final response letters to healthcare complaints are often turning points for complaint journeys, which make the complainant more determined not to give up and sometimes propel them to take further action. In the Australian survey of healthcare regulator complainants, 71% were dissatisfied with the outcome. 7 Our survey results (WP1.1) of participants’ views of cases closed early in the process shows their high levels of disappointment. There was distrust that from the information they have been given that the case was adequately investigated, leading them to consider what further actions they could take under appeal or through recourse to other bodies, such as the ombudsman, against the service provider organisation rather than the registrant. Together, these results show the importance of communications to the public making complaints about professionals and of addressing gaps between systems. Our research exploring how the legal and policy frameworks of the statutory regulators of social work and social care professionals in the UK approach the question of whether a witness at a FtP hearing should be considered as ‘vulnerable’, and the steps that may be taken in response, scrutinises an area of law and policy that has largely remained unchanged since these provisions were introduced to the FtP domain. Taken together with a four-country approach, and the use of a sociolegal methodology, this provides a novel contribution to the growing body of literature that focuses on the impact of the regulation of social work and social care professionals on stakeholders in this process, including service users and their families, as well as having wider application to the regulation of healthcare professionals, and beyond. 77 Challenges faced and limitations The greatest challenge has been working with professional regulators, where their experience of research has been primarily that which they have directly commissioned and which is not subject to the rigorous ethical, legal and governance requirements inherent in NIHR-funded research. Although all regulators were involved to some extent during the proposal development, with seven letters of support and in the set-up period, the legal processes and agreements varied according to each regulators’ requirements for data-sharing and participant recruitment. The time taken to put these agreements in place ranged from 7 to 13 months, which impacted recruitment rates. Some regulators withdrew from data collection for all or some WPs due to competing priorities. The research was largely reliant on regulators to identify participants. The regulators did not have systems in place, for example, via their case management systems, to easily sift through cases to find eligible harmed public complainants or witnesses to invite to participate in the research. Finding and distribution of invitation documents to potential participants required members of regulator staff to undertake the task alongside other duties. In some regulators, this was contracted out to a legal firm that manages investigations and case presentation at hearings. This was not funded within the project. Regulators work under tight resource and legal constraints and unpredictable workloads. There is no equivalent support for regulatory research as there is for the NHS in England under the Health and Care Act (2022), 96 which supports engagement with research. Regulators made decisions about the suitability of people to be contacted and did not share the numbers nor reasons for exclusion systematically. Reasons mostly related to the ‘vulnerability’ of the person, or ongoing complaints being made by the person to the regulator or to other bodies, including via social media and the press. This will have led to unknown bias in our samples. Further, they required cases to be closed before they would make contact for the research team to avoid legal risks that the research could lead to the introduction of new evidence. This may have influenced response rates adversely and added to bias. Regulators differed in their definitions of when a case was closed: some interpreted this as the case having passed the date by which any appeal by the registrant can be made (28 days), while others included the additional 40 days for the PSA to appeal, that is, 68 days after the final hearing has concluded. One regulator also required waiting not only until cases were closed, but for hearings with a reviewable sanction waiting until that sanction was lifted, which could be many months. This did not apply to survey participants where the criterion was simply ‘case closed in the previous 6 months’. For WP2.1, the consent process and legal agreements with regulators concerning the use of personal data required that the public witnesses gave consent to participate in the research before their documents could be accessed by the research team. We also required that those contacted could be identified to a specific case in which they had been involved. Unfortunately, for those public witnesses contacted in WP2.1 with cases closed over the past 5 years, in most instances, the case (identified by the registrant’s details) was not able to be identified in the communications with the witness, so the person could not be consented for the research. This led to several potential interviewees being excluded. In WP2.2, the study was designed when in-person hearings were the norm, where researchers could be expected to meet, informally, the potential participants. This may have led more people to consent to take part. In WP1.1, WP1.5 and WP2, where the contact came from the regulator, this may have adversely impacted recruitment if the witness had not had a very positive experience of contact with the regulator. Further, the lengthy time since the hearing closed may have also compounded this reluctance. However, more significantly, this contact may have come at an unexpected and unwelcome time as it required them to re-engage with past traumatic events that they had put behind them. The process also required effort from the witness to contact the researcher, which generally can be a problem for recruitment. Response rates, while difficult to ascertain for the reasons above, were much lower in all WPs than anticipated. This in turn caused additional work for the regulators to find more cases and unknown response bias. The number of regulators for this research was originally proposed to be eight. This was not based on any systematic knowledge of the number of likely cases since this could not be ascertained before the research was underway. Estimates were based largely on the FtP caseloads of regulators, although it was not possible to know how many of these cases were likely to involve the public and harm. The funding panel advised it was not necessary to seek as many regulators to answer the research questions, therefore the project started with six regulators involved in participant recruitment. However, this decision was reviewed, and additional regulators were brought on board when it was found that some regulators had withdrawn, and others were struggling to find enough public harm cases. Because of the need to bring regulators on board with legal agreements and recruitment processes, this added to the work of the team and the regulators and to further recruitment delays. A change in the protocol was necessary to enable recruitment via social media and the AvMA . This broadened the recruitment base and included cases that were not closed and from other regulators. Engagement with partners and stakeholders The Department of Health and Social Care expects that regulators will work together more closely. 97 This project is the first independently funded regulator research on this topic working across several of the UK’s regulators about their FtP functions. The project provided numerous opportunities for inter-regulator comparison and improvement shared via the Regulator Advisory Group, as well as working with other stakeholders, including the public. We had input from legal firms and professional organisations, registrants’ lawyers and unions, and employers of registrants via our third advisory group (lawyers, employers and professionals) and the Scottish Public Services Ombudsman (SPSO). Through our PAG , we have had discussions with AvMA , the Harmed Patients Alliance, the charity Inquest and the Point of Care Foundation. This widespread and sustained stakeholder engagement has enabled discussions about policy changes in FtP through consideration of new and important ways to improve public protection and to develop new more targeted support and advice for the public (see Recommendations for policy and practice). Individual training and capacity-strengthening activities A PhD programme funded by the Open University (OU) enabled a member of NMC staff to undertake an in-depth study of public involvement in FtP processes at the NMC. The student was able to use some of the research tools for content analysis conducted after the research undertaken for this study. They also benefited from early insights into recruitment processes and findings of this study. A PhD programme co-funded by the OU and the General Osteopathic Council (GOsC) began in 2024. Patient and public involvement A key strength of the project has been the contribution of the public involvement lead, a former police detective with personal experience of FtP , as co-investigator and chair of the PAG . Engagement and commitment from this group to the project was very high from the start, as most public members had personal experience of FtP . The group met five times across the project acting as critical friends, offering advice and feedback on issues around recruitment, emerging findings and the project recommendations. The group was very involved in developing the harm definition for the regulators at the start of the project. One group member described their FtP experience as feeling more like a piece of evidence than a witness and raised the expense incurred for public witnesses to attend the remainder of the hearing. Another member asked why panel members do not question the process as our findings highlighted that the process can be traumatic and terrifying. Group members recognised the experience of the people who were interviewed in the research project; that, there was a lack of help and support to the people raising concerns throughout the whole FtP process and that they felt their concerns had not been investigated thoroughly or fairly. A workshop was held with PAG members in November 2022 to talk through WP1.3 findings and to feed into recommendations for regulators’ web-based public information. The group was sent preparatory work in advance of the workshop and a reminder of the project findings. A platform was created on EdApp to allow members to go through the task online. At the workshop, a collective task was undertaken, building on this preparatory work. The results were fed back into project recommendations. Group members suggested possible attendees for the coproduction workshops 98 in WP3 and the dissemination events held in Dundee and London (see Report Supplementary Material 5 ). There was discussion around whether the coproduction workshops should be conducted in separate groups of members of the public and professionals or mixed. It was agreed that people should be given the choice, although the first meeting was largely focused on those with personal experience of the FtP process. The public involvement co-investigator attended a 2-day analysis workshop in Manchester and was an active contributor to discussions around the project’s emerging findings. He chaired dissemination events and presented project findings at national conferences and events. PAG members attended the first four coproduction events and the dissemination events in Dundee and London. Additional invited members of the public and the PAG members found that the meetings allowed them to discuss their reoccurring concerns that were visually conveyed creatively by using a graphic artist (see Report Supplementary Materials 2 and 3 ). This method was found to be a novel and stimulating approach to capturing perspectives and was used to illustrate findings in our dissemination events. An accessible version of the project has been disseminated to PAG , participants and the wider public. We were mindful throughout that working on the project could be distressing for anyone with personal experience of involvement in FtP . Equality, diversity and inclusion Members of the public are the largest group of people to raise concerns about registrants to regulators. 10 In 2022, the Care Quality Commission found that people from Black and minority ethnic backgrounds are less likely to raise concerns about their care than those from non-Black and non-minority ethnic groups, yet 84% have wanted to. 99 The PSA also highlighted the need to address inequalities, particularly for those who have low digital literacy (e.g. only communicating via e-mail can be a barrier for older people who do not have or use a computer or smart device). The PSA has recommended that FtP processes from start to completion are inclusive, fair and accessible for all. 100 As part of this research (WP1.2), regulator documents and web pages were evaluated for usability, accessibility and readability to assess suitability for members of the public. 73 – 75 A self-advocacy service of people with learning disabilities reviewed regulator Easy Read documents and provided feedback on their usefulness. Our research elicited the perspectives of the public who have raised a concern about a registrant with regulators. Our OpenLearn (OL) resource provides information about our findings and recommendations ( www.open.edu/openlearn/mod/oucontent/view.php?id=144831&section=3 ) It aims to provide insight and understanding about how members of the public experience the FtP process and how best to support people. For the purposes of inclusivity, the resource has been assessed for accessibility and readability to ensure that it is as accessible to as many people as possible. The project website and its contents were also assessed by the OU teams to ensure that they met UK Government’s 101 requirements for accessibility, that the reading age was at least 13–14 years old and that we adhered to our own recommendations about readability of content for members of the public. The OL course acknowledged equality, diversity and inclusion from several perspectives: The authors and critical reviewers of content comprised of people from Black and minority ethnic groups, people with protected characteristics and service users. An OU inclusivity tool was used to produce images and animations. The resources are available to download and view in a range of different formats. They are designed for compatibility with screen readers. This resource is being disseminated to a diverse range of groups, including thousands of OU students, staff, professional networks, regulators lawyers and members of the public. Our research participants included people from diverse ethnicities, and people with protected characteristics such as mental health conditions and disability, although these data were not recorded. Participants represented all nations of the UK across health and social care. Our research team included people with protected characteristics and diverse ethnicities, and with a range of disciplinary backgrounds, such as law, social science, nursing, social work, education, psychology and members of the public with lived experience of FtP processes. Impact and learning Appendix 2 lists the academic papers and conference presentations and social media outputs and all events as described below as well as the project resources, which are being evaluated. The study has already had significant impact on participating regulators. For example, in 2022 and 2023, workshops on findings from WP1.2/WP1.3 were offered to all 13 regulators and were undertaken by 11. They each received a report and a 2-hour workshop to discuss the specific results of their regulator website benchmarked against the others. These were well attended by employees from FtP operations, policy, communications and information technology support. They discussed work already in progress since the completion of data collection as well as plans for new work to be undertaken because of the feedback. This was also reported to the PSA , as they noted that the findings were relevant to some of the planned improvements of the regulators to meet the requirements for accessibility and equality, diversity and inclusiveness. Since project closure, we have tracked changes being made in several regulators’ websites (particularly, the four social work/care regulators), including the use of accessibility, reading-level complexity and accessibilities tools, with direct acknowledgement that this project has informed their improvement work. The project findings and draft recommendations were presented at two project dissemination events held in Dundee and London in 2024. These were by invitation (including to all three advisory group members). The event in Dundee was designed to focus on social care regulation and was co-designed with input from the Scottish Social Services Council (SSSC) and all the social care/social work regulators of the UK. It included a section on the trauma-informed practice approach being adopted in Scotland, with input from psychologists from NHS Education Scotland, specialising in trauma-informed practice, and the Director of Psychology Services of NHS Lothian. Invited attendees included the Director of Social Work for Scotland, the head of the Regulatory Unit of the Scottish Office and social work unions, among others. It also included input from researchers from a current social regulation project involving Social Care Wales (SCW) (NIHR134942). The second event in London included heath as well as social care/social work regulators and related bodies and researchers, including academics from a completed project on complaints (NIHR127357); 95 see Report Supplementary Material 5 for dissemination event attendance analyses. A post-event survey was conducted, which gave very positive feedback. See videos of responses on the project website resources’ page: https://wels.open.ac.uk/research/projects/witness-harm-holding-account/resources . Presentations have been made to regulators, regulatory lawyers and regulatory researchers at the PSA ’s annual conference in November 2023, the Accredited Registers conference in 2024, and a bespoke event that the PSA designed around the project and FtP research in October 2024. A presentation was given to the Association of Regulatory and Disciplinary Lawyers, in November 2023, which was attended by about 150 regulatory lawyers. Relevant to the social care sector, a workshop was provided in November 2024 for case managers and legal advisers of the SPSO . The above events resulted (and are continuing to do so) in debate and engagement with the recommendations and in numerous requests for access to the resources and briefings as well as invitations to undertake further workshops, presentations and blogs. 102 – 104 Presentations have been made to several academic and policy events. Presentations were made of WP2's ethnographic work to academic audiences at the Studying Healthcare using Institutional Ethnography international network (November 2022 and August 2024) and the 20th World Congress of the International Sociological Association (June 2023). In 2024, a presentation was given of analyses of the readability of social care websites to the international Joint Conference on Social Work, Education and Social Development. Presentations have been given to a national learning disability conference on the readability of Easy Read information from regulators, with requests from attendees for access to the readability tools. A presentation to the International Association of Medical Regulatory Authorities, a global organisation of medical regulatory authorities, on the results of the WP1.2 analyses of the GMC ’s websites, again, stimulated interest in the use of the analysis tools of this project. It was notable as being research independent of the medical regulators. An exploratory interdisciplinary paper on constructions of vulnerability was discussed at the Health Policy and Politics Network in April 2024. Work on witness vulnerability was discussed at the Patient Safety Group of the Royal College of Surgeons of Edinburgh. As a result, the project is being publicised via Patient Safety Learning (which is a charity and independent voice for patient safety). A research paper on defining harm from the perspective of the witness from the witness experience findings was presented to the Health Services Research UK (July 2024). With a particular focus of research to inform policy to tackle sexual abuse among colleagues, through the analysis of the public determinations of cases, we identified cases involving harm of all 13 statutory regulators in the UK, a greater scope than prior PSA-commissioned studies. 105 , 106 This new analysis confirmed that sexual harassment and abuse is proportionally more common in GMC cases than across other regulators. Findings from WP2.1 on sexual harm towards junior doctors and the journey of reporting have been used to design events for knowledge exchange and to shape future policy, including the Australasian Summit on Sexual Harassment in Medicine (2023); and Supporting and Reporting Summit was hosted by the Royal College of Surgeons of England (2024). They have formed the basis of invited keynotes and panel contributions at events, including: the Australasian Summit on Sexual Harassment in Medicine (2023); Royal College of Surgeons Council (2023); the Association of Surgeons in Training (2024); Supporting and Reporting Summit, Royal College of Surgeons of England (2024) and Royal College of Physicians and Surgeons of Glasgow (2024). A critical case was also included in a paper for a 2024 Academy of Management conference symposium on voice and silence. 107 With enhanced dissemination funding, we undertook three additional activities. First, a symposium at the international regulators’ conference of the Council on Licensure Enforcement and Regulation (CLEAR), September 2024, included papers on the witness experience, witness vulnerability and employer support for registrants and the public engaged with FtP , with the Director of Policy of the PSA as discussant, along with poster presentations on the web page analyses. 103 Second, the four social care/social work regulators were interviewed to ascertain their progress on conceptualising and providing operational guidance on vulnerable witnesses. Third, a multistakeholder Summit in October 2024 was hosted by the Royal College of Surgeons of England focusing on Supporting and Reporting. The summit included representatives from all levels of the surgical workforce trade unions, other royal colleges, employers and other clinical professionals, NHS leads on domestic and sexual violence, and Baroness Merron, Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health. 104 A summary report on the day is being developed for the Department of Health. Project resources The project produced briefings for regulators, employers and the public, with a plain English version. There are animations created for care workers in social care and service users and their families about the FtP process. These are being promoted to social care employer networks for use in staff training and for their service users. Interactive learning modules with content featuring the findings of this study form a free learning resource for the public and professionals using the globally accessed OpenLearn platform. Six films from the WP2.3 narratives are presented on the Heathtalk.org website ( https://healthtalk.org/a-z/F ). This resource is readily accessed and used in the training of healthcare professions and by members of the public, with over 4 million views per year for its wide range of films. Several regulators and three legal firms are using these resources in staff and panel member training. All resources are free to use, and links along with promotional blogs are hosted on the project website. Events have been offered to all regulators in 2024–5, which have so far included training sessions for panel members, regulator staff and executive leaders of the GDC and Social Work England ( SWE), Chief Executives of all 13 regulators, and for panel members and staff of GOsC , General Chiropractic Council (GCC), GMC , Northern Ireland Social Care Council (NISCC), NMC, SSSC , and the Nursing and Midwifery Board of Ireland, and the Capsticks LLP client conference with over 350 attendees across several regulators including teachers, architects, accountants, veterinary surgeons and farriers, with others in planning (see Appendix 2 ). Lessons learnt for future research The main learning point is that despite the development of new relationships with regulators to conduct research while maintaining independence, it became necessary to additionally introduce alternative routes to recruiting participants. This relationship necessitated not only the creation of the legal and contractual collaboration agreements but also considerable relational work by the team and the regulators to enable the many unforeseen challenges around identification and recruitment of participants and access to documents required by the project to be overcome. Because the regulators have different histories, jurisdictions and processes, as well as being differently resourced, with differing caseloads, the approach to each regulator had to be developed and tailored. This is unlike conducting research in the NHS, where working practices, procedures and organisational systems that support independent research exist. Related work Two PhD projects, referred to above, were derived from relationships developed with regulators while developing and disseminating findings from this study. A further PhD opportunity is being advertised in 2025 arising from this study related to trauma informed practices in FtP proceedings. Implications for decision-makers Current proposals for changes in professional regulation give more power to regulators to determine their processes and achieve resolution of cases without going to public hearings. Based on our findings concerning distrust, we have submitted a response to the PSA ’s consultation, 108 suggesting that these changes could negatively impact on the extent to which public voices are heard and included. We have recommended this also gives opportunities for the regulators to consider how they may take the public’s expectations into account, for example, enabling personal impact statements to be presented at key decision-making points in the process. Beyond that, it is also possible that this research can contribute to the wider debate about alternatives to the adversarial FtP process since we have also suggested that alternative methods such as mediation could be trialled, where the complainants’ position would take more prominence. We have also made suggestions for legislative change in relation to how witness vulnerability is constructed by the regulators of social work and social care professionals. These issues also have implications beyond this sector (and beyond the UK) in circumstances where similar provisions are applicable in the regulation of healthcare professionals and in other types of professional regulation, as discussed with the Teaching Regulation Agency. Our research recommends reforms to FtP , such as trialling victim impact statements and advocates, and alternatives to adversarial cross-examination. It also recommends immediately relevant changes in the resources and communications by regulator employees, legal counsel and panel members, including the use of our project resources in their training, to show the public’s experiences in the current models. Since we found evidence of the harmful effects of the FtP processes on already harmed people, our dissemination events have showcased trauma-informed practices, which are being implemented by the SSSC in line with Scottish Government public policy. Our PSA blog refers to the Scottish government-wide commitment to delivering trauma-informed public services. 102 It is based on research into the experience of sexual trauma victims and victims of other traumatic crimes going through the criminal justice process (see the trauma-informed justice framework). 49 According to NHS Education for Scotland, being ‘Trauma-Informed’ means being able to recognise when someone may be affected by trauma, collaboratively adjusting how public service providers (such as regulators) take this into account and responding in a way that supports recovery, does no harm and recognises and supports people’s resilience. Further, it can be argued that doing so enables people to give their best evidence, which is in everyone’s interests. Witnesses should be protected as far as possible from further harm that might be induced by the FtP process and particularly from adversarial cross-examination. This can include misinterpretation or misrepresenting the impact of the original trauma on the witness or how they give their evidence in the case. Following presentation of our research, The Point of Care Foundation is offering Schwartz Rounds © to support improvement work by regulators (J Cunnett, CEO, personal communication, 2024). This is an approach evaluated by an earlier NIHR-funded study in a healthcare context. 109 From WP1.4 findings, we recommend that the employers of registrants and those in leadership roles in the services should review the support they provide to their patients or service users and their families and colleagues beyond that provided for local complaints investigations. The project resources may provide useful training materials for all staff about their role in FtP and the support that they may provide to those in their care who may engage with FtP . Recommendations for policy and practice Our findings suggest that the FtP process is experienced as unjust by public witnesses (patients, service users and friends) and can generate additional harm for public referrers. This harm is an outcome of embedded practices that lead to experiences of epistemic injustice, 79 , 80 disrespect 78 , 110 and disposability. Our coproduced recommendations should be read within this context and the inherent limitations on regulators of their current legal duties and rules. For government 1. We reiterate a key recommendation from Tackling Concerns Locally (2009, p. 58) concerning medical regulation: ‘People who wish to raise concerns – whether patients, carers or other members of staff including trainees – should be encouraged to do so and supported throughout the process {locally through to the regulator}’ (p. 8). It recommends ‘ advice and clearer signposting for those considering raising a concern; support in articulating the concern, including advocacy support for vulnerable people ’ (p. 55). 83 This should include confidential advice and clearer signposting for those considering raising a concern; support in articulating the concern, advocacy support; and support as the concern is progressed, including for witnesses at FtP hearings. 111 Much of this advice has not been implemented in relation to the health service, 82 and it is not apparent in relation to FtP . For regulators and employers 2. Regulators and employers in health and social care should review and extend informational, well-being and emotional support to people known to their services, for example, patients, members of the public, registrants and colleague witnesses involved in FtP processes. Independent advocacy 3. Regulators and employers should signpost public referrers to sources of independent advocacy and advice across the various processes, including inquests, civil proceedings, NHS complaints, social services complaints and criminal cases. For regulators 4. Recognise the key role public referrers have in FtP processes. 5. Develop a holistic understanding of how FtP processes can be experienced by public referrers: their motivations for making a complaint, the impact of the unfamiliarity of these processes, the work involved for the referrer and harm caused by communications that may be experienced as overly legalistic or disrespectful. 6. Recognise that public referrers may be distressed, or retraumatised by all stages of FtP processes, and as such that they should: 6.1. minimise the need for public referrers to retell their story and ensure that all staff/lawyers are aware of their communication preferences, communicate deadlines and adhere to them 6.2. take all efforts to consider how fairness, kindness, respect and humanity can be demonstrated in all interactions with people. 7. Consider how good practices and guidelines from other areas of law may be used in FtP processes to: 7.1. support all witnesses to give their best evidence 7.2. recognise the different ways in which people may be made vulnerable in and by FtP processes 7.3. expand the opportunities for witnesses to explain to regulators and hearing panels about the personal impact of the case, for example, using victim personal or impact statements. 8. Establish feedback mechanisms or review current approaches to ensure continuous feedback from people who have raised concerns (including those whose cases do not proceed to hearings) to assess their experience and use that to improve FtP processes. Information provision 9. Support members of the public to understand FtP processes and decision-making steps. 10. Provide clearer public-facing information, coproduced with members of the public, about the steps that can be taken to support people to raise concerns and to provide evidence as a witness, throughout the process, and at a hearing. 11. Public-facing information should be designed to be understood by most of the UK adult population by being compliant with UK government website accessibility, and public health education requirements, including being worded to be understood by those with limited literacy and available in alternative audio–visual formats. 12. A liaison function to employers, where this does not already exist, could improve the selection and management of cases and identify issues which may fall on the employer to support the witnesses. Communication 13. Approach communication with public referrers as a two-way dialogue, as opposed to a one-way transmission of information, to allow public referrers to feel valued and heard in the FtP process. This will involve, for example: 13.1. clearly explaining the function and purpose of the process, and for each case, explain why aspects of a case might not be included, or a referral may be closed 13.2. actively listening to and, as far as possible, addressing people’s concerns about the process 13.4. recording a statement of their concerns and the impact of these concerns, which should be available to regulator staff throughout the case (see 7.2 and 7.3) 13.5. establishing the preferred means of communication, amount of information and timings of communications with the public referrer and others affected by the referral and make this available to regulator staff throughout the case 13.6. keeping people affected by the referral regularly updated on progress. In the event of unavoidable delays, explain as clearly as possible why this has happened and what will happen next. This should include ongoing communication across the whole progress of a case, for example throughout adjournments 13.7. ensure decisions are communicated by appropriate staff members using the preferred means of communication (see point 13.5) who can answer questions. 14. Review the use of terminology and provide staff training in trauma informed, respectful and empathetic engagement and communication. The hearing 15. The process of cross-examination can generate additional harm for witnesses. Regulators should support witnesses to understand what it is like to be a public witness and go through cross-examination, including: clearly explaining what happens at a hearing; the purpose of cross-examination and what sort of questions they may be asked in cross-examination; what actions witnesses can take when giving evidence, such as asking for breaks and for questions to be rephrased; and acknowledgement that cross-examination is broadly understood to be inherently stressful and difficult. 16. Panel members (especially, the Panel Chair) and legal advisers should better understand the experience of public witnesses and intervene in inappropriate and distressing cross-examination. 17. Where appropriate, and in conjunction with the public witness, consider whether alternative or modified approaches to cross-examination may be possible within existing FtP processes. More broadly, consider whether alternatives to the adversarial approach can be sought out and evaluated. 18. Support witnesses to observe proceedings after they have given evidence if they want to. 19. Online hearings should ensure that all attendees have their correct and/or anonymised name and role on display. 20. Witness and other interested parties should receive feedback and support after the hearing and the opportunity to make sense of the outcome. Research recommendations Following research on satisfaction with the communication of health and social care service complaints ( NIHR 127367), 95 and the current study, we recommend that organisational interventions should include training in affiliative communication. 112 This could include a collaborative communication style of listening to and identifying complainants’ issues and needs when engaging with the regulator. We therefore recommend that communication interventions that have been developed for public complainants in the health and social care contexts are adapted and evaluated for use in the regulatory context. Similarly, training regulator staff, legal advisers and panel members in trauma-informed practices is being implemented in at least one regulator and could be evaluated in relation to public engagement in and experience of the FtP processes. Evaluation of conversations with the regulator and public participants in FtP at any stage of the process could be evaluated, for example by conversation analysis 113 (as in NIHR 127367), 95 to ascertain the extent to which the public are able to fully tell their story and how that story has been taken account of in the FtP process (or not). Such analyses could examine whether responses that are recommended in the trauma-informed justice model, for example, giving choice, acknowledging the impact of past trauma on retelling, etc., are present and what difference this makes from the public’s perspective. Questions for future research How can health and social care regulators better communicate throughout the FtP process with the public who raise concerns and/or who may become witnesses? What is the impact of difficult experiences of the FtP processes on public (dis)trust in regulators and/or professions/services? How can public witnesses be better supported to give evidence in a way that they find more empowering and less distressing? How effective are communication interventions, including trauma-informed practices, along the FtP journey? To what extent can victim’s personal or impact statements be used in FtP processes to provide opportunities for witnesses to explain to regulators and hearing panels about the personal impact of registrants’ actions? From the public’s perspectives, how useful are the regulator support services, independent services and support services commissioned by regulators, such as Victim Support. What is the experience for the public regarding the expressions of apology and regret by registrants? From the public’s perspective, what is the impact of current and new FtP processes, including consensual disposal? How do health and social care regulators assess the situational vulnerability of all public witnesses and how are the special measures implemented and with what effects? Conclusions Understanding the role of the public and their contribution to health and social care professional regulation required research to be conducted with instigators of, and witness in, the FtP process. It has required a multiregulator focus, since research commissioned by regulators, including the PSA , does not span the full breadth of regulatory practice across the 13 regulators of health and social care professionals in the UK. We employed multiple qualitative methods to generate data from stakeholders: the public, regulators, employers, professional bodies, unions and FtP lawyers. Further, we undertook research that is upstream of the FtP process by including employers of professionals who provide services to service users and patients and who arguably can put in place means of reducing the risks of harm to them if they are involved in FtP . Drawing together our conclusions, we revisit the study’s research objectives. 1. Examine the experiences of patient/family/and colleague witnesses in the different stages of FtP processes, including initial contact; engagement, other complaint/investigations related to their contact with the registrant and services involved; the hearing stage; cross-examination processes; and the outcome/sanction and their responses to admissions and expressions of apology, or regret by the registrant . This objective was largely met. Survey data (WP1.1) evidenced the disappointment felt by most of the harmed members of the public who raised a concern with the regulator, but whose case was closed prior to a hearing. While this is unsurprising, it also drew attention to the importance of clear and empathic communication with members of the public who make a complaint, so they can understand how their concerns have been investigated, and to maintain trust in the regulator, professionals and providers of services. Our research involved the public who had been harmed by a registrant, and who were a witness at a hearing, who we found often felt that their concerns and the impact of the event itself were not fully taken account of in the case pursued by the regulator. The regulatory experience for public members was described as generating further harm, the processes of the regulators as being transactional, and in some cases, disrespectful and lacking compassion. The cross-examination process was described by the public, lawyers and by panel members as being adversarial, and recommendations for how this process could be improved overall were discussed. Some offered modifications to the process, such as the use of personal impact statements to better understand how events have impacted on public, or suggested other processes such as mediation. Apology and expressions of regret were noted to be part of the mitigation of registrants, and their authenticity was questioned. The only part of this objective that we were unable to address was WP1.5, which aimed to interview public witnesses supported by two regulators’ in-house support services. This was because the potential participants did not agree to be interviewed. 2. Conduct a systematic analysis of the content and user experience of existing FtP information, resources and interventions for witnesses . This objective was met. Public-facing web information was analysed for all the regulators and tribunal services in WP1.2, and the public’s views were elicited in WP1.3. Analyses of content showed very wide variation – from too much to too little information to inform the public’s decisions about raising a concern and being a witness. The readability levels were found to be more complex than recommended in health research and by the UK Government for public services 101 The accessibility of websites was often below standard, meaning some people with cognitive, visual and other disabilities would be excluded. The task of finding out how to submit a concern showed that even for highly educated people, the low levels of usability of all but two of websites were a challenge, which could deter or obstruct people from making complaints, particularly from marginalised communities. 3. Identify where and how these processes and interventions could be improved to benefit complainants and witnesses and improve the efficiency of regulation. We made 20 recommendations, mainly for regulators to improve current systems and staff and panel member practices, in the context of the inherent power imbalance between the public and regulators. Employers were recommended to offer support to patients and service users and families involved in FtP . 4. 4. Codevelop and coproduce ‘good practice’ guidance and resources for a range of stakeholders, namely the public, regulators, health and social care employers and regulated practitioners. Coproduction 98 was used in WP4 to shape the recommendations and to inform the specifications of the OpenLearn resources. Following engagement with regulators, there is evidence of immediate and sustained uptake of resources to be used by regulators in the training of staff and panel members, including the personal narratives on healthtalk.org, as well as engagement with the professions and public who play such a key role in FtP . Concluding remarks The research has provided a global first of multiregulator health and social care research into the role of the public in FtP , conducted and funded independently of the regulators. We recommend improvement to professional regulation through public-focused information, compassionate, kind 93 and trauma-informed communications and support 49 and for independent cross-regulator evaluation of these interventions. Our study makes a novel and important contribution to research on professional regulation, which also contributes to the wider body of patient safety research. This research provides evidence of the experience of the public in whose name professional regulation takes place, who often find the process unjust and disappointing. Additional information CRediT contribution statement Louise Wallace ( https://orcid.org/0000-0003-3770-0580 ) : Writing – original draft, Conceptualisation, Formal analysis, Data curation, Funding acquisition, Investigation, Supervision, Methodology. Sara Ryan ( https://orcid.org/0000-0002-7406-1610 ) : Writing – reviewing and editing, Conceptualisation, Formal analysis, Data curation, Funding acquisition, Investigation, Methodology. Rosalind Searle ( https://orcid.org/0000-0002-6052-7627 ) : Writing – reviewing and editing, Conceptualisation, Formal analysis, Data curation, Funding acquisition, Investigation, Methodology. Gemma Hughes ( https://orcid.org/0000-0003-2930-1125 ) : Writing – reviewing and editing, Conceptualisation, Formal analysis, Data curation, Funding acquisition, Investigation, Methodology. Annie Sorbie ( https://orcid.org/0000-0002-1504-4167 ) : Writing – reviewing and editing, Conceptualisation, Formal analysis, Data curation, Funding acquisition, Investigation, Methodology. Gemma Ryan-Blackwell ( https://orcid.org/0000-0003-4425-0020 ) : Writing – reviewing and editing, Conceptualisation, Formal analysis, Data curation, Funding acquisition, Investigation, Methodology. Sharif Haider ( https://orcid.org/0000-0002-9333-8240 ) : Writing – reviewing and editing, Conceptualisation, Formal analysis, Data curation, Funding acquisition, Investigation, Methodology. Other contribution Richard West ( https://orcid.org/0000-0002-0267-7539 ) : Other contribution. Acknowledgements First and foremost, the authors would like to thank those members of the public and the health and social care employers who took part in this research. We thank the Professional Standards Authority and the 13 professional regulators who gave their support for this research and took part in the Regulators’ Advisory Group. We thank 8 regulators who took part in participant recruitment and the 11 regulators who took part in feedback from the web analysis part of the research. We thank the hearing clerks and officers who facilitated our observations of live hearings. We also wish to thank members of our Professionals, Lawyers and Employers Advisory Groups, including Carmel Lloyd and Suzanne Miller of Royal College of Midwives, Lien Watts and Dianna Stevenson of the British Association of Social Work, Catherine Riddle, Oxford Health NHS Foundation Trust, and Mark Whiting of Capsticks, LLP and Harjinder Saundh of Thompsons, LLP. We thank the chair of the Public Advisory Group, Mr Richard West as public co-investigator, along with the members with lived experience of FtP ; Derek Richford, Patricia Alban and Rosie Tozer who have family experience of FtP , as does Sarah Seddon, of the Harmed Patients Alliance. We also thank those whose organisation represents people with lived experience of FtP ; Peter Walsh as outgoing CEO of the Association against Medical Accidents, Deb Coles CEO of Inquest, Bev Simmonds and Jessie Cunnett, past CEOs of The Point of Care Foundation, who together constituted our Public Advisory Group. We thank our project advisors Professor Graham Pike, Professor Neil Thompson, Dr Erica Bowen and Vicki Lawson-Brown for their invaluable professional insights throughout this project. We thank George Julian for their support of the Public Advisory Group and for social media dissemination. We thank the NIHR Study Steering Committee members for their critical review and steadfast support throughout the project: Professor Yvonne Birks (Chair), Professor Keiran Walshe, Professor Anne Gallagher, Katherine Timms, Alison Ledward, Ian Thomas, Nicholas Hart and Angela Mayes. Data-sharing statement All data requests should be submitted to the corresponding author for consideration. Access to anonymised data may be granted following review. For a list of further publications, conferences, social media and other outputs, see Appendix 2 . Ethics statement Ethical approval was sought, and subsequent amendments were submitted for review by the lead university for the work package. Approvals were granted on, for the overall plan of research, 2 July 2022 by the Open University, HREC 4058. Ethical approval, and subsequent amendments, were granted on 22 October 2021 by the Health and Education Research Ethics and Governance Committee at Manchester Metropolitan University (EThOS reference number 35942). Ethical approval and subsequent amendments were granted on 25 September 2021 by the University of Glasgow College of Social Sciences Research, Ethics Committee No. 4002100050. Ethical approval was granted by University of Edinburgh, School of Law, on 24 February 2023. Information governance statement The Open University is committed to handling all personal information in line with the UK Data Protection Act (2018) and the General Data Protection Regulation (EU GDPR) 2016/679. Under the Data Protection legislation, The Open University is the Data Controller, with collaborating universities being joint Data Controllers of personal data collected for the purposes of this research. You can find out more about how we handle personal data, including how to exercise your individual rights and the contact details for our Data Protection Officer: www5.open.ac.uk/library-research-support/RDM-policy . Disclosure of interests Full disclosure of interests: Completed ICMJE forms for all authors, including all related interests, are available in the toolkit on the NIHR Journals Library report publication page at https://doi.org/10.3310/SSPP1118 Primary conflicts of interest: Louise Wallace declares membership of the following: DH National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme (2012–5, 2020–2); she was Senior Scientific Adviser to the Health Services and Delivery Research programme (2015–9) and to the NIHR Dissemination Centre (2019–20). She was Trustee of the UK Public Health Register (2015–21). She was a Lay Member of General Dental Council Fitness to Practise Panels 2015–25, and is Lay Adjudicator in Fitness to Practise panels for Social Work England since 2019 and Social Care Wales since 2025. She is a member of the GOsC patients forum. Sara Ryan declares membership of the NIHR Research for Social Care (RfSC) Funding Committee (2021–3) and NIHR Research Programme for Social Care (2023–current), and she is a Trustee of MLCP Care Link and Speak Out Forum. Rosalind Searle is a member of the Royal College of Surgeons of England Working Party for Sexual Misconduct in Surgery. She is a member of NHS England's Working Party on domestic abuse and sexual violence. Annie Sorbie has previously undertaken work for various regulators as a solicitor in practice (2001–15) and as a regulatory consultant (2016–7). Prior to this project, she had undertaken commissioned research on behalf of the General Medical Council and the Professional Standards Authority. At the time of conducting the research, she was a Lay Member of the Patient Safety Group of the Royal College of Surgeons of Edinburgh. Department of Health and Social Care disclaimer This publication presents independent research commissioned by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR , MRC, NIHR Coordinating Centre, the Health and Social Care Delivery Research programme or the Department of Health and Social Care. This synopsis was published based on current knowledge at the time and date of publication. NIHR is committed to being inclusive and will continually monitor best practice and guidance in relation to terminology and language to ensure that we remain relevant to our stakeholders. Funding This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR131322. Award publications This synopsis provided an overview of the research award Improving patient, family and colleague witnesses’ experiences of Fitness to Practise proceedings: a mixed methods study. Other articles published as part of this thread are: Ryan-Blackwell G, Wallace LM. Witness to Harm; holding to account: what is the importance of information for members of the public who give evidence and may be witness in a regulatory hearing of a health or care professional? Health Expect 2024; 27 :e14168. https://doi.org/10.1111/hex.14168 Haider S, Wallace LM. How readable is the information the united kingdom’s statutory health and social care professional regulators provide for the public to engage with Fitness to Practise processes? Health Expect 2024; 27 :e70067. https://doi.org/10.1111/hex.70067 Wallace LM, Greenfield M. Employer support for health and social care registered professionals, their patients and service users involved in regulatory fitness to practise proceedings in the UK. BMC Health Serv Res 2024; 24 :1268. https://doi.org/10.1186/s12913-024-11646-0 Sorbie A, Garippa L. (Re)constructing ‘witness vulnerability’: an analysis of the legal and policy frameworks of the statutory regulators of social work and social care professionals in the UK. Br J Soc Work 2025; 55 :744–62. https://doi.org/10.1093/bjsw/bcae185 Hughes G, Ribenfors F, Ryan S, Wallace LM, Searle RH, Mueller A, et al . Iatrogenic injustice: an institutional ethnography of Fitness to Practise hearings. Soc Sci Med 2025; 382 :118331. https://doi.org/10.1016/j.socscimed.2025.118331 For more information about this research please view the award page ( www.fundingawards.nihr.ac.uk/award/NIHR131322 ). About this synopsis The contractual start date for this research was in September 2021. This article began editorial review in May 2024 and was accepted for publication in June 2025. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The Health and Social Care Delivery Research editors and publisher have tried to ensure the accuracy of the authors’ article and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this article. Copyright Copyright © 2025 Wallace et al . This work was produced by Wallace et al . under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. 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List of supplementary material Report Supplementary Material 1. Advisory groups and SSC membership Report Supplementary Material 2. Work package 4 infographic Report Supplementary Material 3. Work package 4 visualisation report Report Supplementary Material 4. Work package 4 attendance analysis four workshops Report Supplementary Material 5. Dissemination event attendance analysis Supplementary material can be found on the NIHR Journals Library report page ( https://doi.org/10.3310/SSPP1118 ). Supplementary material has been provided by the authors to support the report and any files provided at submission will have been seen by peer reviewers, but not extensively reviewed. Any supplementary material provided at a later stage in the process may not have been peer reviewed. The supplementary materials (which include but are not limited to related publications, patient information leaflets and questionnaires) are provided to support and contextualise the publication. Every effort has been made to obtain the necessary permissions for reproduction, to credit original sources appropriately, and to respect copyright requirements. However, despite our diligence, we acknowledge the possibility of unintentional omissions or errors and we welcome notifications of any concerns regarding copyright or permissions. Glossary Allegations These are the concerns that have been raised in relation to whether a registrant is fit to practise. This term may also be used to describe a formal written document which sets out the basis on which it is claimed that a registrant’s fitness to practise is impaired. Determination This is the written outcome of a fitness to practise proceeding. These are published after a case has been decided and may have private matters redacted and personal details anonymised. Disposal This is another word for the final decision in a fitness to practise case which is often used in regulatory proceedings. Fitness to practise This is a regulatory term that is used to describe the processes professional regulators use to address concerns that they receive about their registrants. These concerns may relate to matters, including (but not limited to) a registrant’s competence, conduct or criminal conviction or caution. It can also be used to refer to a registrant’s eligibility to be and to remain on a regulator’s register. Sanctions These are the steps that may be taken when a registrant’s conduct falls short of the standards that are expected of the relevant profession. For example, this may include (but are not limited to): an admonishment or warning, conditions on registration, temporary suspension of registration or removal of registration (also sometimes known as erasure or striking-off). List of abbreviations AvMA Action against Medical Accidents CLEAR Council on Licensure, Enforcement and Regulation FtP fitness to practise GCC General Chiropractic Council GDC General Dental Council GMC General Medical Council GOC General Optical Council GOsC General Osteopathic Council GPhC General Pharmaceutical Council HCPC Health and Care Professions Council NIHR National Institute for Health and Care Research NISCC Northern Ireland Social Care Council NMC Nursing and Midwifery Council OU Open University PAG Public Advisory Group PSA Professional Standards Authority PSNI Pharmaceutical Society of Northern Ireland SCW Social Care Wales SPSO Scottish Public Services Ombudsman SSSC Scottish Social Services Council SWE Social Work England WP work package References 1. Professional Standards Authority. What is Fitness to Practise?. 2014. URL: www ​.professionalstandards ​.org.uk/news-and-updates ​/news/what-fitness-practise (accessed 4 December 2025). 2. 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J Serv Mark 2022;36:379–97. 10.1108/JSM-09-2020-0382 [ CrossRef ] 113. Heritage J. Conversation Analysis as Social Theory. In Turner BS, editor. The New Blackwell Companion to Social Theory. Oxford: Blackwell; 2008. 10.1002/9781444304992.ch15 [ CrossRef ] Appendix 1. Recruitment of participants, cases and determinations TABLE 1 Human participant data View in own window WP1.1 survey Regulator recruitment Sent Regulator recruited Social media % of regulators GDC 59 9 1 13.50 NMC 60 10 16.70 SWE 32 11 34 GPhC 30 7 23.20 GOC 38 16 42 SSSC 61 6 9.80 GMC 2 HCPC 1 PSNI 5 1 20 60 64 Total 285 21.05% Work package 1.3 Recruitment was by invitation by two regulators to their public consultee lists and AvMA . Respondents were recruited as follows: Interviews – AvMA (six), SWE (two), focus group General Pharmaceutical Council (GPhC) (seven). Work package 1.4 Twenty-seven were contacted, and 25 employers interviewed; included diverse types of employers and they were related to 11 statutory regulators. Work package 1.5 Unknown number of participants were eligible and were contacted by NMC and GDC , but none were recruited. Work package 2.2 Ethnographic observations: 15 hearings, 71 days of observations, across eight regulators: GDC , NMC, SWE , GPhC , General Optical Council (GOC), SSSC , GMC , GOsC and GCC . TABLE 2 Participants in WP2 (regulator, role and WP) View in own window Count of WP Column labels Row labels 2.1 2.2 2.3 Grand total CW 1 1 FM 3 3 Hearing PM 3 3 Public – patient/service user referrer/witness (PW) 5 2 7 GDC totals 5 3 6 14 CW 1 1 FM 1 1 Public – patient/service user referrer/witness (PW) 3 2 5 GMC totals 1 3 3 7 CW 2 2 Public – patient/service user referrer/witness (PW) 2 1 3 GOC totals 2 2 1 5 CW 1 1 Public – patient/service user referrer/witness (PW) 2 2 GOsC totals 3 3 CW 1 1 FM 1 1 Regulator staff 1 1 RL 1 1 GPhC totals 4 4 CW 1 PSNI totals 1 1 FM 1 1 Public – patient/service user referrer/witness (PW) 2 2 HCPC totals 2 1 3 FM 1 2 3 Public – patient/service user referrer/witness (PW) 1 2 1 4 NMC totals 2 2 3 7 Public – patient/service user referrer/witness (PW) 1 1 RL 1 1 SSSC total 2 2 CW 1 1 SWE total 1 1 Grand total 21 12 14 47 CW, colleague witness; FM, family member; PM, panel member; PW, professional witness; RL, regulator’s presenting lawyer. TABLE 3 The WP2.1 determinations data View in own window Name of regulator Total no. of registered professionals (at time of search) Date of list No. of FtP cases (May 2021–May 2022) No. confirmed as harm % proportion of harm cases with misconduct by no. of registrants % total cases of harm SWE 96,315 31 March 2021 911 20 0.95 2.20 GCC 3432 31 December 2021 14 6 0.41 42.86 GOsC 5427 31 March 2021 18 6 0.33 33.33 GDC 113,960 31 December 2020 329 10 0.29 3.04 HCPC 286,914 31 March 2021 654 31 0.23 4.74 PSNI 2824 31 May 2021 6 1 0.21 16.67 SSSC 166,634 6 June 2022 259 31 0.16 11.97 GOC 32,276 31 March 2021 48 3 0.15 6.25 SCW 35,802 31 March 2021 53 14 0.15 26.42 NMC 731,918 31 March 2021 1029 63 0.14 6.12 GMC 344,172 31 June 22 407 19 0.12 4.67 NISCC 52,013 31 March 2021 43 3 0.08 6.98 GPhC 81,290 31 March 2021 17 0 0.00 0.00 TOTAL 1,952,977 3788 207 Appendix 2. Project outputs Peer-reviewed publications Ryan-Blackwell G, Wallace LM. Witness to harm, holding to account: what is the importance of information for members of the public who give evidence and may be witness in a regulatory hearing of a health or care professional? Health Expect 2024; 27 :e14168. Haider S, Wallace LM. How readable is the information the United Kingdom’s statutory health and social care professional regulators provide for the public to engage with fitness to practise processes? Health Expect 2024; 27 :e70067. Wallace LM, Greenfield M. Employer support for health and social care registered professionals, their patients and service users involved in regulatory fitness to practise proceedings in the UK. BMC Health Serv 2024; 24 :1268. Ryan-Blackwell G, Wallace LM, Ribenfors F. A novel content and usability analysis of UK professional regulator information about raising a concern by members of the public. Health Expect 2024; 27 :e70027. Wallace LM, Greenfield M. Engagement of health and social care employers in professional regulatory fitness to practise – employers’ missed opportunities? BMC Health Serv Res 2025; 25 :255. https://doi/10.1186/s12913-025-12343-2 Sorbie S, Garippa L. (Re)constructing ‘witness vulnerability’: an analysis of the legal and policy frameworks of the statutory regulators of social work and social care professionals in the UK. Br J Soc Work 2024; 55 :744–62. https://doi.org/10.1093/bjsw/bcae185 Hughes G, Ribenfors R, Ryan S, Wallace LM, Searle R, Mueller A, et al . Iatrogenic injustice: an institutional ethnography of Fitness to Practise hearings. Soc Sci Med 2025; 382 :118331 https://doi.org/10.1016/j.socscimed.2025.118331 Searle RH, Garippa L. Social, cultural & structural factors in reporting: A paradigmatic case study of medical trainee sexual abuse. SSM Qual Res Health 2025; 8 :100638. https://doi.org/10.1016/j.ssmqr.2025.100638 Wallace LM, Ryan-Blackwell G. Exposing wrongs and protection of others: A novel analysis of people harmed by a health and care practitioner whom they have reported to the professional’s regulator. J Nurs Regul (in review). List of additional papers in preparation Searle R H, Garippa L, Ameliorating further harms from professional misconduct: exploring a multi-level trust repair process. JMR . Hughes G, Wallace L, Ryan S, Searle R, Sorbie A, Ribenfors F, West R. Experiencing and defining forms of harm: public witnesses and Fitness to Practise Hearings. Health Expect . Conferences Hughes G, Ribenfors F. Witness to Harm: Tracing the Ruling Relations in Fitness to Practice Hearings Studying Healthcare Using Institutional Ethnography International Network , online 15 November 2022. Hughes G. Witness to Harm: Tracing the Ruling Relations in Fitness to Practice Hearings . 20th World Congress of the International Sociological Association. Paper – online June 2023. Wallace LM, Haider SH. How Easy Is to Report a Concern About a Doctor, Nurse or Someone Giving You Care? Does It Help to Have Easy Read Leaflets? Poster. Social History of Learning Disability conference, Milton Keynes, July 2023. Wallace LM, Ryan-Blackwell G, Haider S, Greenfield M. Witness to Harm: A Multimethod Study of Public Engagement with the UK’s 13 Statutory Health and Care Professional Regulators’ Fitness to Practise (FtP) Processes: The Open University Research Day . Milton Keynes, July 2023. Searle RH. Invited Keynote – Sexual Harassment and Abuse in Surgery . Association of Surgeons in Training, Bournemouth, 9 March 2024. Searle RH. Australasian Summit on Sexual Harassment in Medicine (23 October 2023), Old Parliament House, Canberra, Australia – Roles: (1) designing the summit and participants, (2) contributing to a panel, (3) leading table for those involved in regulation to outline what to expect from reporting and (4) and leading table on how to improve prevention. Searle RH. Invited Keynote – ‘Breaking the Silence’ . Royal College of Physicians and Surgeons of Glasgow. Medicine 24 (2024), 25 October 2024. Wallace LM. How Inclusive Are the General Medical Council’s Website Compared to Other UK Health and Care Regulators for Fitness to Practise Public Referrers and Witnesses . Paper presented in person at the International Association of Medical Regulatory Authorities, Bali, November 2023. Sorbie A, Hughes G. Improving Patient, Family and Colleague Witnesses’ Experiences of Fitness to Practise proceedings: A Mixed Methods Study (‘Witness to Harm, holding to account’) . Association of Regulatory and Disciplinary Lawyers Annual Conference, London, November 2023. PSA Conference November 2023 Wallace LM. Improving Patient Family and Colleague Witnesses Chances of Fitness to Practise Proceedings: (‘Witness to Harm; Holding to Account’) . Project overview and survey findings of public experiences when a case is closed pre hearing. Searle RH, Garippa L. Comparative Analysis of Types of Harm and Fitness to Practise Witness Experiences . Hughes G, Ribenfors F. Ethnographic Study of Fitness to Practise Hearings . Ryan S. Narrative Accounts of Public Experience of the Fitness to Practise Process . Sorbie A. Considerations from an Examination of the Social Care Fitness to Practise Context . Discussant Peter Walsh, AvMA . Posters: Wallace LM, Greenfield. Employer Support to Witnesses in Professional Regulatory (Fitness To Practise) Proceedings . Ryan-Blackwell G, Wallace LM. A Content Analysis of Professional Regulator Information for Public Witnesses in a Fitness to Practise Hearing . Haider S and Wallace LM. How Easy Read Our Regulators Fitness to Practise Website Resources? Wallace LM. Professional Standards Authority Annual Conference for Accredited Registers Improving patient, Family and Colleague Witnesses’ Experiences of Fitness to Practise Proceedings: A Mixed Methods Study (‘Witness to Harm, Holding to Account’) . London, February 2024. Haider S. How Readable and Accessible Are the Websites of the UK’s Social Work Regulators by the Public? Paper presented in person at the Joint Conference on Social Work, Education and Social Development, Panama, April 2024. Hughes G, Sorbie A. Constructions of Vulnerability in Health and Social Care Policy and Law: An Interdisciplinary Exploration Health Policy and Politics Network , Manchester, May 2024. Hughes G, West R. Experiencing and Defining Forms of Harm: Public Witnesses and Fitness to Practise Hearings . Paper presented in person at the Health Services Research UK, Oxford, July 2024. Ryan-Blackwell G, Haider S, Wallace LM. Witness to Harm: Holding to Account. Evaluation Of the Context and Readability of Information for the Public in Fitness to Practise Hearings . Health Services Research UK, Oxford, July 2024. Hughes G, Ribenfors F. Witness to Harm, Holding to Account: An institutional Ethnography of Fitness to Practise Hearings. Witness to Harm: Tracing the Ruling Relations in Fitness to Practice Hearings, Studying Healthcare Using Institutional Ethnography International Network , online, 20 August 2024. Searle RH, Garippa L. Accumulative Harms and Betrayals: A Qualitative Case Study of Silencing and Epistemic Injustice in Medicine. In Symposium. Michael Knoll, Jennifer Ho, Roberta Fida, Anindo Bhattacharjee, R H. Searle, Elizabeth Wolfe Morrison, Catherine Connelly, Lotta Dellve, Ivan Marzocchi, Matteo Ronchetti, Wim Vandekerckhove and Lewis Garippa. Broadening the Focus: Toward a Contextualized Understanding of Employee Voice and Silence . Academy of Management Conference August Chicago, Proceedings , 2024. https://doi.org/10.5465/AMPROC.2024.12194symposium Searle R. NHS ‘The Big Coffee Break’ Roundtable Discussion: Speak Up, Listen Up. 10 October 2024 (recording link youtube.com/watch?v=2mkhejwCu7Q&feature=youtu.be ). Symposium Council on Liscensure Enforcement and Regulation Conference, Baltimore, USA, September 2024. Learning for regulators from public’s experiences as witnesses in fitness to practise proceedings. Wallace LM. Introduction and Overview . Sorbie A. ( Re)constructing ‘Witness Vulnerability’: An Analysis of the Legal and Policy Frameworks of the Four Statutory Regulators of Social Care in the UK . Searle RH. Insight into Sexual Misconduct Cases . Wallace LM. How Do Employer Organisations Engage with FTP Cases Involving Their Employees and Patients/Service Users and What Is Their Role in Supporting These People? Discussant: Dinah Godfree, Head of policy, Professional Standards Authority, UK. Ryan-Blackwell, Haider S, Wallace LM. Witness to Allegations: A Content Analysis of Professional Regulator Information for Public Witnesses in a Fitness To Practise (FtP) Hearing . Poster. Wallace LM, Greenfield M. Employer Support to Witnesses in Professional Health and Social Care Regulatory (Fitness to Practise) Proceedings in the UK . PSA research conference – witness to harm, November 2024 Wallace LM, West R. Improving Patient, Family and Colleague Witnesses’ Experiences of Fitness to Practise Proceedings: A Mixed Methods Study (‘Witness to Harm, Holding to Account’) . Plenary. Wallace LM. Introduction . Ryan-Blackwell G, Haider S. Analysis of 13 Regulators Websites . Wallace LM. Being a Public Witness in FtP Experiences of Public and Colleagues (Survey) . Hughes G. Experiences of Public Witnesses of Fitness to Practice Hearings . Searle RH, Garippa L. Investigations and Closure Before a Hearing . Sorbie A. Witness Vulnerability and Social Care Professional Regulation . Wallace LM, Greenfield M. Employers’ Support for Registrants and Public Who Raise a Concern . Wallace LM. Recommendations Including for Future Research . Ryan-Blackwell G, Haider S. Project Resources and Initial Evaluation by Users . Discussant – Richard West. Searle RH, Garippa L. Journey to Reporting Sexual Harassment and Abuse: Escalating Harms and Social and Organisational Factors . Professional Standards Authority Academic Conference, London; 2024. Searle RH. Supporting and Reporting Summit. Royal College of Surgeons , October 2024, London. Roles: (1) co-designing the summit and its participants, (2) contributing to a panel on the future direction to improve supporting and reporting, (3) designing group task using WP2.1 cases and (4) contributing to final report to Minister. Searle RH. Presentation – ‘ Working with Practitioners and Policy Makers in Health – Journey with Regulators, Professional Bodies and Employers ’; designed and delivered symposium ‘ Creating and Sustaining Impact ’, European Network of Organisational Psychology Annual Workshop, Paris, 26–27 March 2025. Searle RH. #MeToo: Breaking the Silence within Critical Care Nursing. British Association of Critical Care Nurses Conference, Blackpool, October 2025. Wallace LM, Ryan-Blackwell G. Witness to Harm; Holding to Account: Improving Patient, Family and Colleague Witnesses’ Experiences of Fitness to Practise: Lessons for the Intrepid . Faculty of Wellbeing and Education Research Meeting. The Open University, November 2025. Wallace LM. Harms and Secondary Harm of the Public and Colleagues Engaged in Professional Regulation – Invited Presentation to the Harm and Evidence Research Centre, The Open University, 13 May 2025. View in own window Social media and e-newsletters Media Content Audience Films of London dissemination event https://wels ​.open.ac ​.uk/research/projects ​/witness-harm-holding-account/resources Audience comments on recommendations by regulators, the public and the Point of Care Foundation, Public engagement in the project Commentary on social care regulation and witness vulnerability Commentary by the team on why the project is an important implication for social work and regulator research Public, regulators, professionals, employers, lawyers Blogs www ​.professionalstandards ​.org.uk/news-and-blog ​/blog/detail/blog ​/2024/04/04/customer-care--personalised-care---it-s-just-not-good-enough ​.--more-compassion-is-needed-in-complaints-handling E-newsletter: www ​.professionalstandards ​.org.uk/news-and-blog ​/blog/detail/blog ​/2024/04/04/customer-care--personalised-care---it-s-just-not-good-enough ​.--more-compassion-is-needed-in-complaints-handling PSA – compassion and trauma-informed practices and FtP Regulators Social Care Wales-blog by Hywel Dafydd, Assistant Director of Regulation with a project description for their research database (November 2024) Blog about the research findings and recommendations and resources Social care employees and employers Intermediaries for Justice – Newsletter (December 2024) Commentary on relevance of the project for intermediaries who may work in professional regulation in future Intermediaries in the justice system Royal College of Surgeons of England – Supporting and Reporting Event. September 2024. Blog (December 2024) Describes the use of the project findings to inform discussions, and final report Medical professional leaders, employers, regulators and legal counsel Professional Standards Authority https://www ​.professionalstandards ​.org.uk ​/news-and-updates/news ​/being-seen-and-being-heard (October 2025) Describes two studies using studies of people who complain (or not) to regulators Presentations and training to regulatory and professional bodies and lawyers GDC (April–June 2024) Presentation and discussion on witness experience and panel member’s practice Panel member training GDC (May 2024) Presentation and discussion of findings and recommendations GDC staff GDC (October 2024) Presentation and discussion of findings and recommendations GDC Executive Leadership Team SWE (October 2024) Presentation and discussion of findings and recommendations All SWE staff SWE (November 2024) Presentation and discussion on witness experience and panel member’s practice Panel member training Royal College of Surgeons Council (November 2024) Presentation Council members Scottish Public Services Ombudsman (19 November 2024) Findings from WP2 Ombudsman case workers Australian Health Practitioner Regulation Agency (December 2024) Presentation Staff members GOsC (14 January 2025) Presentation and discussion on witness experience and panel member’s practice Panel member training PSA Policy Director’s Network (2025) Project findings, WP2.1 and recommendations for regulators Policy leads from 10 health and social work regulators SSSC – Panel members (January 2025) Project findings, witness vulnerability, and recommendations for regulators, witness experiences, resources Panel members NISSC (March 2025), Nursing and Midwifery Board of Ireland (March and May 2025) and GCC (2 May 2025) Project findings, recommendations and resources Social care regulators, Board members, panel members employees and registrants GOC (Autumn 2025) Project findings, recommendations and resources Optical professionals and employers GCC (12 June 2025) Project findings, recommendations and resources Chiropractic Board, staff and panel members GMC (3 June 2025) Project findings, recommendations and resources Panel members and staff (150 attendees) Intermediaries for Justice (March 2026) Project findings, recommendations and resources Intermediaries who may work in professional regulation in future Capsticks LLP (Client Conference, 24 March 2025) Project findings, recommendations and resources 350 legal professionals, professional bodies and employers CEOs’ Forum CEOs of 13 UK health and care regulators 12 CEOs attended NMC (2 September 2025) Executive meeting GDC (9 September 2025) Sexual Misconduct in Dentistry: Insights and initiatives professional bodies, regulators, lawyers, academics British Association of Critical Care Nurses (7 October 2025) #MeToo: Breaking the Silence within Critical Care Nursing Nursing professionals and academics GOC panel Newsletter (December 2025) Project resources Panel members Project resources https://wels ​.open.ac ​.uk/research/projects ​/witness-harm-holding-account/resources Resource Content Audience Films of one of the two project dissemination events Views of attendees Public, regulators and academics’ views of London event Briefings Public-focused summary of project and resources Regulator and wider stakeholder summary of project and resources Public Regulators, professionals, lawyers, professional organisations and defence bodies, researchers OpenLearn Online topics designed for the findings and recommendations about FtP process, with animations and learning and reflective activities Public Professionals, regulators and employers, lawyers and defence bodies Two animations explaining FtP Explaining what is FtP , the regulators, what they can/cannot investigate, professional responsibilities and standards, reporting, being a witness, outcomes The public Social care employers/employees Healthtalk.org Six online edited narratives of public experiences from those who had experienced harm by a registrant and their experience of FtP Public, educators of professionals, regulators’ staff, regulatory lawyers Blogs on project website https://wels ​.open.ac ​.uk/research/projects ​/witness-harm-holding-account ​/blog/council-licensure-enforcement-and-regulation Blog by Wallace, LM Serale R, Sorbie A on Presentations at CLEAR Conference, September 2024 Regulators in any country https://wels ​.open.ac ​.uk/research/projects ​/witness-harm-holding-account ​/blog/“witness-harm”-nihr-research-inputs-royal Blog by Searle R on Presentation to Royal College of Surgeons, October 2024 Medical regulators https://wels ​.open.ac ​.uk/research/projects ​/witness-harm-holding-account ​/blog/“witness-harm”-nihr-research-inputs-royal Blog by Sorbie A on her publication and updates on witness vulnerability Regulators (Re)constructing witness vulnerability in the regulation of social work and social care professionals in the UK: catalysing change The construction of witness vulnerability within the legal and policy texts of the four UK social work and social care professional regulators. Report Regulators About the Series Health and Social Care Delivery Research ISSN (Electronic): 2755-0079 Article history The contractual start date for this research was in September 2021. This article began editorial review in May 2024 and was accepted for publication in June 2025. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The Health and Social Care Delivery Research editors and publisher have tried to ensure the accuracy of the authors’ article and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this article. Last reviewed: May 2024; Accepted: June 2025. Copyright © 2024 Wallace et al . This work was produced by Wallace et al . under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/ . For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited. Bookshelf ID: NBK619835 DOI: 10.3310/SSPP1118 Share Views PubReader Print View Cite this Page Wallace L, Ryan S, Searle R, et al. Witness to Harm-Holding to Account. Improving patient, family and colleague experiences of Fitness to Practise proceedings: A mixed-methods study. Southampton (UK): National Institute for Health and Care Research; 2025 Dec. (Health and Social Care Delivery Research, No. 13.44.) doi: 10.3310/SSPP1118 PDF version of this title (1.2M) In this Page Introduction Aims, objectives and research questions Methods for data collection and analysis Discussion Patient and public involvement Equality, diversity and inclusion Impact and learning Implications for decision-makers Recommendations for policy and practice Research recommendations Conclusions Additional information List of supplementary material Glossary List of abbreviations References Recruitment of participants, cases and determinations Project outputs Other titles in this collection Health and Social Care Delivery Research Related information NLM Catalog Related NLM Catalog Entries PMC PubMed Central citations PubMed Links to PubMed Recent Activity Clear Turn Off Turn On Witness to Harm-Holding to Account. Improving patient, family and colleague expe... Witness to Harm-Holding to Account. 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