White elephants

By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 3 March 2017

Ahead of the much-awaited annual NHS staff survey on 7 March, and the data therein about NHS safety culture, this is a snippet of update about a body that may become yet another NHS transparency white elephant.

The Healthcare Safety Investigation branch (HSIB) – which was established to conduct important NHS safety investigations and lead improvement on NHS investigation quality 1 –  was a fine idea  but has it has suffered several assaults by the government.

The Department of Health located HSIB within NHS Improvement, one of the bodies that HSIB may need to hold to account. This resulted in much outcry about issues of independence, including by the parliamentary select committee that proposed HSIB’s establishment. The latter protested that the government’s actions were “intolerable”. 2

Keith Conradi HSIB Chief Investigator – and former Chief Inspector of the Air Accidents Investigation Branch – announced in January that he was seeking statutory independence and additional powers. The outcome of this is awaited. 3

Jeremy Hunt galloped in on one of his political hobbyhorses and announced that the “independent” HSIB should look at maternity safety in its first year. 4

HSIB’s capacity was restricted to 30 investigations a year, albeit with the later clarification by Keith Conradi HSIB Chief Investigator that investigations could involve multiple cases. 3

In 2015 the Air Accident Investigation Branch, upon which HSIB is modelled, received 596 notifications and of these conducted 32 (5%) field investigations and 194 correspondence investigations. 5

AAIB investigations in 2015.png

Pro rata, 5% of the annual NHS tally of about 30,000 reported serious incidents 6  is 1500. The figure of 30 HSIB investigations a year looks thin in this context.

There were also controversies about HSIB ‘safe space’ and proposals for disclosure of filtered information and not original documents to patients and families, which are yet to be resolved. The government thought it might be a good wheeze to roll out ‘safe space’ to trusts as well, but campaigners, charities and Conradi have resisted this.  3 7

It was also unclear if HSIB would consult about the drafting of its protocols. After enquiries to HSIB, invitations were extended to some individuals and organisations, but with no transparency about this. In particular, there has been no answer to several questions about whether HSIB will involve whistleblowers

Indeed, correspondence from Keith Conradi seemed to suggest that a finalised protocol for “dealing with whistleblowers” would be published as a fait accompli.

Jane Rintoul –  HSIB Director of Corporate Affairs, who is in fact a Deputy Director at the Department Health seconded to HSIB – has latterly taken over this correspondence by HSIB. This itself is interesting. She has so far given only broad assurance that there will be opportunities to continue refining HSIB’s protocols:

We are still very much in the design phase and will continue to refine our protocols after going live. We see the input of a broad range of stakeholders, including whistleblowers, as key.”

However, providing post hoc opportunities to comment on a government fait accompli is hardly inclusive, good practice.

As Steven Shorrock, who lectures on safety and Human Factors and is Editor of Hindsight, a safety magazine for air traffic controllers, commented:

“…my view is that healthcare is many times more complex & messy than aviation.” 9

Painting by numbers will not dent the NHS Denial Machine. Conradi et al need to engage proactively with the human realities of how the NHS underbelly operates, in order to get on top of their brief.

They also need to model better transparency and inclusivity, in order to be taken seriously as the exemplar that they were meant to be.

That’s if the Department of Health lets them.

Let’s hope that HSIB does not follow the senior NHS pack down the rabbit hole, as exemplified by the recent revelation that CQC and NHS Improvement are planning a conference on learning from deaths that does not, apparently, include families.

Ironically, only two months ago, a major conclusion of the so called CQC Deaths Review which spawned this conference, is that the NHS does not involve families enough when responding to deaths. 10

Lip service, without sincerity, never did lead to much learning.

This is some of the correspondence about HSIB consultation:

Click to access hsib-correspondence.pdf

This is a leaked letter about CQC and NHSI’s family-free conference on deaths, and a related blog by Connor Sparrowhawk’s mum:

Click to access cqc-nhsi-letter-to-trusts-17022204-learning-from-deaths.pdf

My son is not a teaching tool…

This the last annual report issued by AAIB on Keith Conradi’s watch:







1 Investigating clinical incidents in the NHS. Public Administration Select Committee, 27 March 2015


2 PHSO review: quality of NHS complaints investigations, Public Administration and Constitutional Affairs Committee 2 June 2016

7. However, we agree that Parliament can and should provide additional safeguards and direct oversight so that the Secretary of State is not exposed to any suspicion of untoward ministerial influence. We therefore reiterate the recommendation that there should be primary legislation to provide that HSIB shall be established as a separate body, independent from the rest of the NHS, in order that it can conduct – and be seen to conduct – fully independent investigations. As part of NHS Improvement HSIB will be vulnerable to improper influence and is likely to find itself in the impossible position of having to include the body of which it is a part in its own investigations. We cannot accept the decision to dilute a core principle of the new Investigation Branch, and believe that there is a clear consensus across the sector that the proposed arrangements are an intolerable compromise.”


3 NHS has ‘nothing to fear’ from new investigation body, says chief, Health Service Journal 5 January 2017


4 Transcript of speech by Jeremy Hunt 3 March 2016 at the Global Patient Safety Summit

I have asked the new organisation to consider focusing initially on maternity and neonatal mortality investigations to give us time to examine and understand its effect before rolling it out to other areas of clinical activity.”


5 AAIB Annual safety review 2015


6 Department of Health consultation: Providing a ‘safe space’ in NHS safety investigations October 2016

There are 30,000 serious incidents reported annually, and each one should trigger an investigation (although many are at Trust level).”


7 Department of Health ‘safe space’ proposal could legitimise cover ups, AvMA November 2016


9 Tweet by Steven Shorrock 23 February 2017

10 Report of CQC Deaths Review. Learning, candour and accountability. December 2016

Click to access 20161213-learning-candour-accountability-full-report.pdf

6 thoughts on “White elephants

  1. I don’t know how you keep your self-control, Dr A. But, I thank you for this post.
    However, I am left seething.
    Another bolt-on entity undoubtedly designed to be an obstacle rather than a solution, another nominal fig leaf with transparency engineered to be opaque, and more able people recruited and being disabled before they have begun.
    I won’t witter on – it’s Friday night and I have nothing constructive to say except thank you.
    Have a good weekend.


  2. Safety culture in the airline industry, particularly in relation to incident investigation and human factors, seems far more advanced than in the NHS. The case for statutory independence of the HSIB and the additional powers Keith Conradi is seeking seems overwhelming. However, the ambiguous “dealing with whistleblowers” phrase attributed to him is disturbing if it reflects a view that people who raise concerns in the public interest are troublemakers to be “dealt with” (i.e. neutralised/denigrated/disposed of) – I hope not. I hope that the Public Accounts Committee maintains a strong interest in the HSIB, intervening as appropriate.

    Liked by 1 person

  3. Thanks. The comment is not just attributed to Conradi but was made by Conradi. See the correspondence, and his email of 6 January, at 11.16. I agree it implies at best a lack of sufficient understanding or recognition that whistleblowing is a resource and not a problem.

    Liked by 1 person

  4. All I can say is I met NHSE Patient Safety Director Dr Mike Durkin founder of HSIB (formerly IPSIS) he said Parity of Esteem was “just a catchphrase meaning different things to different people”
    I dont believe HSIB will be “fit for purpose” unless major changes are considered!

    Liked by 1 person

  5. Is HSIB just more window dressing? It seems to me that if Mr. Conradi is any good at the job and starts to lift the lid on some of the scandalous NHS cover up he will soon be replaced by someone more willing to protect those at the top. Looks to me that he is caught between a rock and a hard place surrounded by government spies.

    Liked by 2 people

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