• Keith Conradi accepts problems but says he is confident of improvement
  • He reveals plans for a shadow board for HSIB to improve governance
  • HSIB has commissioned two independent evaluations of its work

The chief investigator of the Healthcare Safety Investigation Branch has accepted the new body has made mistakes but told HSJ it was now on an upward trajectory and will improve its governance.

In a wide-ranging interview with HSJ after multiple current and former staff raised concerns about the investigation body’s operation, chief investigator Keith Conradi said he was disappointed to hear their comments, but stressed HSIB had to evolve rapidly, which has been difficult.

Mr Conradi also acknowledged problems with the rollout of new maternity investigation work, which he accepted had been hit by delays in publishing final reports, and had also slowed down its national investigations. HSIB became operational in April 2017 with a mandate to carry out up to 30 national investigations a year on a budget of £3.8m. But in November that year it was asked to take on a further 1,200 maternity incident investigations annually from April 2018.

Governance and management

Speaking about concerns over governance and “caesarian” management, Mr Conradi said: “It is disappointing to hear some of those comments. It is a start-up operation, I know it’s been going for a couple of years, most people have come from very stable organisations with big departments whereas we have had to start everything from scratch and for some people that puts them in a position that doesn’t suit them.”

He added: “The perception of staff is hugely important and yes it does concern me that people feel this way. We need to think as a team why they feel that way even if we think the reality is otherwise…This is evidence that it still isn’t absolutely sorted, and we will continue to refine it. We are now approaching a period where we can stabilise things.

“I do feel the responsibility of the organisation.”

He said HSIB was now on a “changing trajectory” and its executive team had grown from three to six. He rejected suggestions he was “caesarean” in his approach to decision making, but said there had been a lot of “firefighting” initially with quick decisions needed.

“We have been waiting to get to a place where we can think more strategically, which we are now getting to. We didn’t feel comfortable with three of us in the exec team …. We are in a much better position now,” Mr Conradi said.

Mr Conradi, who previously headed up the Air Accident Investigation Branch, said he was looking to establish a shadow board ahead of anticipated legislation which would make it a statutory body with a formal board. He also planned to carry out a staff survey and create a new senior management team beneath the executive. HSIB has also commissioned two evaluations of the impact of its work.

Mr Conradi declined to comment on concerns raised about the departures of the former director of investigations and head of corporate services who both left HSIB suddenly and without warning in 2018.

He said these were individual cases and historic, and said staff could not be made aware of all processes going on behind the scenes. He said proper processes were followed.

Maternity investigations

Responding to concerns that HSIB was too slow in producing maternity reports and not sharing learning as rapidly as trusts would like, Mr Conradi accepted mistakes were made early in establishing the process.

He said: “I think we expected to get the reports out more quickly. I thought we would, I thought they would be more straightforward and the six month term [required period for investigations to be completed] would be achievable. We have had to change and we are trying to improve the process.”

He explained the delays had been caused by two issues: the quality of report writing and back and forth exchanges between trusts and families. He said writing a good investigation report was an underrated skill and getting that right had taken “longer than anticipated”.

He said the process for trust/family exchanges had been changed, and investigators were meeting regularly with trusts to feedback learning rather than waiting for reports.

He acknowledged taking on more than 1,000 maternity incident investigations had been “a tall order” but said: “It was tough and if you accept the fact we have made some mistakes in the early days, actually we have got better and better as time has gone on.”

Mr Conradi admitted it had “slowed down the pace of the national investigations because some of the existing manpower had to be diverted” into the maternity work.

Asked about the costs of training maternity investigators and providing them with equipment to work from home which was then written off Mr Conradi said the cost of having to write-off equipment “was worth it compared with the cost of housing them in offices all over the place. We think this is the best value for money.”

National investigations

Mr Conradi said the suggestion national investigators had been allocated cases in a “taxi rank” system was incorrect, but there had been problems because the team only had 12 members. He said: “We have to moderate where we can use people and sometimes there is just a practical reality to that. Have we always had a team to do investigations yes we have? It might not be the ideal team in terms of what experience we have got but we have always been able to be put a team out to go and do it. We have got smarter in putting people on investigations.”

Pushed on whether the national team should be expanded he said HSIB had no funding to increase its size.

Mr Conradi defended the decision to write off equipment purchased for maternity investigators working from home and said he was confident HSIB was providing value for money for taxpayers.

Safety watchdog hit by poor governance and culture