Poor governance and cultural problems at the Healthcare Safety Investigation Branch have damaged staff morale and led to confused decision making according to multiple whistleblowers, who told HSJ it had also seen major delays to its reports and needed to be “put back on track”.

Other insiders at the safety watchdog who spoke to HSJ said it had been shaken by challenges in the past 18 months as it rushed to take on a new role of investigating more than 1,000 NHS maternity incidents.

Serious problems highlighted include:

  • Poor governance and oversight, and directive “caesarean” management by chief investigator Keith Conradi in what was until recently an executive team of just three people.
  • Long delays to investigations of maternity incidents, and concerns about the standard of its national safety investigations.

The branch now employs around 200 full-time equivalent staff with a budget that has jumped from £3.8m in 2017 to almost £20m in 2019.

Seven insiders who spoke to HSJ individually on condition of anonymity described a litany of complaints including how money was being spent, the way in which decisions were made, the use of consultants and internal conflicts between teams and the sudden departures of two former directors who left HSIB without warning last year.

One source close to HSIB’s senior management in recent years said: “I am a huge supporter of the concept of HSIB and really believe in what they are trying to do. It’s work that needs to be done. But there are some really major serious cultural, behavioural and structural problems at HSIB.

“Keith has a huge amount of integrity. He is a nice guy…but his blind spot is that he wants to have the ultimate say on everything and has people around him who want to be the one whispering in the ear of the king.”

A senior person who was involved in establishing HSIB told HSJ: “There are lots of people who are really committed and believe in the mission but there are some people who are not as experienced and probably out of their depth.

“Operationally it was frustrating with confused processes, made more difficult by people being over committed to ways of doing things and not being open to suggestions, feedback wasn’t really listened to.”

Minutes of a meeting of HSIB’s independent advisory panel in November show members expressed concerns that too many actions and decisions sat with Mr Conradi. They also raised concerns about the quality of some national investigation reports, and poor responses to external feedback.

Sources told HSJ the branch lacked good governance and oversight. It is hosted by NHS Improvement, which provides its resources, but under government directions the body is operationally independent from NHSI and the Department for Health and Social Care.

One staff member told HSJ: “ Keith has surrounded himself with a close cohort of advisers who rule the roost. Keith is very much caesarean. He doesn’t like being held to account.”

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.

Then in November 2017 it was asked to take on 1,200 maternity incident investigations annually for the NHS from April 2018, requiring a significant expansion of staff and increase in its budget to almost £20m this year. To do this HSIB needed to develop new methods and recruit more than 150 maternity investigators on one-year fixed contract secondments from the NHS.

In an interview with HSJ, Mr Conradi accepted mistakes were made while the body was being established, and rapidly expanding, but argued it was now in a better place and continued to improve. He said it was planning changes that would improve governance, ahead of planned legislation to make it a statutory body. These included a shadow board, an expanded management team and independent evaluations of its work.

HSJ’s investigation has revealed:

  • Concerns about delays in maternity investigations being completed, with many delayed and taking substantially longer than the six-month requirement. One NHS chief nurse told HSJ: “It’s taking over six months to get reports back. We are uncomfortable that the opportunities for learning, especially any immediate learning, are being lost.” Brighton and Sussex University Hospitals Trust board has also described delays of more than nine months as “catastrophic” with medical director George Findlay saying the trust had “lost the relationship with the families”. By 19 March this year only two reports had been completed although this rose to 14 by the end of April. HSIB said more than 60 were going through its quality assurance process. It apologised for delays and said developing the nationwide team in 15 months had led to “inevitable confusion” and issues for which it apologised. It said it was delivering regular feedback to trusts now, along with 90 per cent engagement from families compared with 30 per cent under the previous NHS model.
  • Maternity investigators work from home on a one-year fixed contract and are provided with a mobile phone, laptop, work desk, chair, printer, computer screen and a safe storage box. While mobile phones and laptops are returned to HSIB the other equipment is written off at an estimated cost of £30,000 a year. HSIB said this was more financially viable than to pay for cleaning, testing and storage.
  • HSIB has spent £494,726 on a bespoke training course for its 153 maternity investigators, delivered by Cranfield Safety and Accident Investigation Centre. Insiders say investigators do not have to pass any formal assessment at the end of the course which costs almost £1,200 per person, indicating it may not be adequate. HSIB said staff were “continually assessed” during the course and afterwards by their team leader.
  • Sources complained about how national investigators were being allocated to cases in what was described as a “taxi rank” system without reference to their individual expertise. Mr Conradi told HSJ there had been issues with the allocation of team members which was inevitable with a small team. HSIB said the case load of its investigators was monitored and they could seek subject matter expertise as required.
  • The former director of investigations Lucas Hawkes-Frost and former head of corporate services Jane Rintoul, who was on secondment from the Department of Health, both left HSIB suddenly last year and without serving a notice period. HSIB refused to comment on the departures but did say it had “never paid off any member of staff” or used so-called “special leave”. The director of investigations post was not filled until April 2019 by Stephen Drage.
  • For the year to March 2019 HSIB spent £33,000 on eleven senior staff receiving on-call allowances which insiders said was unnecessary and a waste. HSIB said a review had been carried out which concluded the model of allowances complied with NHS policies.
  • Professor Carl Macrae, whose research helped establish HSIB, left his part-time position with the branch earlier than planned this year. Professor Macrae said this was in part to re-focus on his academic work but also because he felt “I had done as much as I could inside the organisation to help steer it in the right direction. As with any major new initiative, there will be a range of challenges and teething issues.” He said HSIB had a responsibility “to actively model the culture of openness and learning it seeks to encourage in the wider healthcare system. They must now develop robust investigation methods, model a culture of openness and learning, work tirelessly and intelligently to drive systemic change – and ultimately speak truth to power.” He called on it to publish an investigation strategy, accounts of its methodology and processes, and evaluations of its impact.
  • As an example of internal cultural problems HSJ was given differing accounts about the creation of an IT database for investigators. One source said this was developed by staff “who didn’t work closely enough with other people in the team” and was used more like a performance management tool which inspectors had to “work around”. But another source said this was a good system that was liked by investigators but was abandoned after the involvement of corporate services and external consultants which damaged morale and made staff unhappy. HSIB said its IT systems had needed to rapidly change and it was planning to replace them with a single system in coming months. It said it had invested in an IT team that would be expanded as HSIB grows.

Whistleblowers’ concerns

One insider told HSJ that many of its problems stemmed from having to rapidly accommodate the 1,200 maternity investigations and the staff and corporate processes needed.

One source said: “The internal capacity has been a much bigger challenge than what people realised.

“The maternity development was a real mistake to take on. HSIB had been operational for less than a year and hadn’t produced a single report. It was very ill-advised to put that on HSIB. It was another pressure that wasn’t helpful. It felt like an enormous ask.”

Another raised fears over the cost of training, writing off equipment costs and the delays in getting maternity reports finished. They said: “Having observed HSIB closely during its first year I have grave concerns that its operational model is neither fit for purpose nor provides value for money.”

They claimed a lack of formal assessment meant the quality of maternity investigations could be variable adding it needed to be independently evaluated to ensure value for money.

Another whistleblower told HSJ the safety branch “offered so much and could have been a breath of fresh air for the NHS”.

But the staff member added: “Keith… and the exec team need to accept responsibility, and someone really needs to open the books on the organisation and its values.”

They echoed concerns of other staff around governance within a small executive team, adding: “The advisory panel was never going to hold Keith or the executive to account. It needs a real board with proper scrutiny of Keith and those around him.

“All I want is HSIB to be put back on track.”

Another insider told HSJ the organisation had been naïve in bringing together different people with different backgrounds, adding they were “utterly paralysed in needing discussion and consensus on everything”.

This whistleblower blamed the expansion of HSIB’s corporate services team which they say had huge influence over the organisation which caused “confusion and tension,” adding: “It became so polarised and the investigations team became deeply frustrated.”

Another internal source at HSIB raised questions about the branch’s spending of its funds, stating: “I would describe Keith Conradi as a genuinely nice man; however, I am not sure some members of his executive team could be described in the same way.

“There has been an enormous spend on corporate services which people are not sure is completely necessary. HSIB is an organisation of approximately 180 people and yet the corporate function is massive with a large number of senior management costing the branch a massive amount of money…and being paid an on-call allowances on top.”

Another source with knowledge of the investigation process criticised the way investigators were allocated cases. Investigators were tasked with incidents not in their areas of expertise, the source said. “It does make it harder than it needs to be. A big impact of this was on morale with people wondering why, having spent years in one area, they weren’t investigating those sort of incidents.”

In response to the comments HSIB said it had training programmes in place and was investing in organisational development. It acknowledged problems with the maternity investigation process but said this was now improving with better feedback to trusts.

A spokeswoman insisted it was achieving its goals and objectives, but said it was planning to launch a “learning review” of its functions after its first full two years.

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Safety watchdog hit by poor governance and culture