More secret HSIB reports and failures of HSIB maternity investigations

By Dr Minh Alexander retired consultant psychiatrist 31 May 2022

Under FOIA, NHS England/Improvement reluctantly disclosed in April 2022 a suppressed and lack lustre King’s Fund report into poor culture and leadership at the Healthcare Safety Investigation Branch:

HSIB whistleblowers and the Secret King’s Fund Fact Lite report

There was a reference in the King’s Fund report to HSIB staff dissatisfaction with previous reviews into cultural issues:

“…At the beginning of the work, staff had been clear that they would not trust the report outcomes if they were first shared with the executive team, owing to a perception that the findings of previous reviews had been changed before publication, or not shared at all.”

At the conclusion of the King’s Fund review, the level of staff distrust was such that it was recommended there should be external oversight of follow up actions and clear timescales for action:

“Given the level of mistrust expressed by staff that senior leaders had failed to act on previous review recommendations, it is important that the HSIB executive team, supported by NHS England and NHS Improvement and with oversight from the Department of Health and Social Care, commit to responding to this report with HSIB staff and confirm the timescale for implementation of these recommendations.”

Following the trail, I asked NHSE/I to disclose copies of the earlier reviews cited by the King’s Fund.

Today NHSE/I disclosed only a single internal review by HSIB senior staff, the Benson review, carried out in 2020, as follows:

“An internal review of our maternity team was undertaken in 2020. This was led by Dr Nick Woodier, Dr Dawn Benson and David Landreth at HSIB. From this review, a slide deck report was produced and delivered in June 2020.”

Dawn Bensonand Nick Woodier are listed as HSIB national investigators.

David Landreth is according to his Linkedin entry HSIB Associate Director of Information Management & Technology

“The review…was commissioned by and for the review of the Exec. Team at HSIB. They wanted to understand stakeholder’s opinion of the maternity services. There were responses back from 54 trusts and a total of 247 staff, mainly midwifery but also other clinical and medical leads including ambulance staff. The idea was to use that feedback, in confidence, to understand what themes HSIB should address to improve our practices within the maternity team when undertaking an investigation.”

The context of this is that the maternity investigation section of HSIB was established as an addition in 2018 and is based in the regions.

NHSE/I redacted information from the Benson review report claiming Section 41 FOIA exemption:

“The info was shared in confidence to HSIB by its staff to improve how its maternity functions operates. The information that has been shared is not trivial and has not been published elsewhere. Given the circumstances in which this information was provided, we consider it was imparted in circumstances giving rise to an obligation of confidence.

Furthermore, we consider that disclosing this information would cause detriment to the confiders and there is an expectation that this type of information should not be disclosed under the FOI Act.”

The reflex secrecy by NHSE/I was such that even though the regulator had disclosed the report authors’ names to me, it still redacted their names from the body of the report:

Child psychologists probably call that self-soothing behaviour.

This is the disclosure email by NHSE/I:

NHSE/I FOI response email 31 May 2022 2204-1746212 NHSE:0023756 HSIB

This is the version of the Benson report disclosed by NHSE/I:

NHSE/I FOI disclosure Benson review report Maternity Formative Evaluation

This is a disclosed HSIB action log dated December 2020, arising from the Benson report:

NHSE/I FOI disclosure Benson review Maternity Formative Evaluation Action Plan

The version of the Benson report disclosed by NHSE/I is similar to the previously disclosed King’s Fund report. It is very light on facts and full of opinions and summary conclusions that are not grounded in data.

It may be that a separate and very different version was produced for senior management consumption, but withheld from the troops.

Nevertheless, there are indications of serious cause for concern.

For a national body which sits in judgment of others, the Benson review made alarming findings of lack of basic structure and standards or common understanding of operating procedure in the maternity section of HSIB.

For example:

“10.3. Define the methodological approach taken to investigate events

Reports demonstrate a fundamental confusion between a method and methodology.
Reports do not clearly define the methodological approach to the investigation, which is strongly rooted in clinically reviewing the event. Rather they list the methods used to collect evidence.
Reports suggest a human factors approach is taken, but that in itself is not a methodology.

There is an opportunity to define the methodology and distinguish between methods and methodological approaches”

“IO 11. Focus on quality

Quality was explored recurrently through the evaluation with questions around quality of reports, analysis and recommendations.
There is a need to balance quality with efficiency, with early learning shared with trusts to help bring about changes.
There is no defined standard of ‘[Redacted]’ resulting in poorly written reports and recommendations that might not offer more than a standard, local, serious incident investigation. ‘[Redacted]’
Quality should include listening and responding appropriately to Trust challenges to findings and factual accuracy.

There is an opportunity for the maternity programme to define standards for quality throughout their investigations, including report writing, report content and recommendation writing.”

“10.2. Design and implement an investigation framework

There is little evidence in either the investigation process or reports, of the appreciation of systems factors which may have contributed to events.
The programme does not have the methodological framework to enable delivery against the directions to ‘identify all contributory factors that led to the outcome’. The investigation process lacks a basic methodological structure which means there is no analytical framework to guide investigations.
Findings are reached by clinicians who, where possible, evaluate what was done against what national and local guidance suggests should have been done. Where there is no such guidance, they review evidence, and influence and shape the recommendations, through their own clinical, and in some cases medico-legal experience. This often leads to reports which suggest responsibility for outcomes lie with the clinical practice of individuals and teams and fail to consider the systems of work which contribute to the outcome.

There is an opportunity to develop and introduce a framework for investigation planning, evidence collection and analysis, which supports investigators to identify all the contributory factors that led to outcomes.”

The Benson review acknowledged that many of the shortcomings arose from the fact that HSIB was forced to expand rapidly when it had to take on national maternity investigations, far outstripping its original capacity.

The review of course did not say so, but the origin of that malaise was political, with Jeremy Hunt’s maternity safety crusader agenda driving the expansion.

This was the relevant extract from Hunt’s announcement to parliament in November 2017 that HSIB would massively expand to take on a thousand maternity investigations a year:

“When it comes to maternity safety, we are going to try a completely different approach. From next year, every case of a stillbirth, neonatal death, suspected brain injury or maternal death that is notified to the Royal College of Obstetricians and Gynaecologists’ “Each Baby Counts” programme—that is about 1,000 incidents annually—will be investigated not by the trust at which the incident happened, but independently, with a thorough, learning-focused investigation conducted by the healthcare safety investigation branch. That new body started up this year, drawing on the approach taken to investigations in the airline industry, and it has successfully reduced fatalities with thorough, independent investigations, the lessons of which are rapidly disseminated around the whole system.

The new independent maternity safety investigations will involve families from the outset, and they will have an explicit remit not just to get to the bottom of what happened in an individual instance, but to spread knowledge around the system so that mistakes are not repeated. The first investigations will happen in April next year and they will be rolled out nationally throughout the year, meaning that we will have complied with recommendation 23 of the Kirkup report into Morecambe Bay.”

The Benson review gathered the following concerns about the quality of maternity reports as follows:

Feelings that quality is driven by ensuring that the investigations have input and direction from clinical professionals.
A limited quality assurance review process against standards for reports before they are released. There is evidence of poor formatting, grammar and spelling in reports.
Evidence that the process does not fully take account of factual accuracy challenges with inclusion of changes or clarification to those challenging the report as to why changes have not been made.
Recommendations are generally lower in the hierarchy of effectiveness of recommendations and do not commonly focus on system improvements, rather guidance and policy. Trusts reported concerns that some recommendations were not linked to evidence or causality.
A repeated concern was the delay to receipt of actions from reports. This meant that trusts were not able to put in place early learning to help prevent similar invents and instead had to wait till the final report which may be a year later.
The review team also heard of individual cases that undermined the intention for HSIB to provide no-blame investigations via the way local staff have been interviewed.”

The Benson review listed areas for improvement as follows:

“Improvement Opportunities

IO 1. Define roles so that individuals are responsible for functions within their expertise.
IO 2. Design and implement an investigation framework.
IO 3. Define the methodological approach taken, and methods to be used to investigate events.
IO 4. Empower maternity investigators to lead their investigations.
IO 5. Review the expertise of the investigation team and consider introducing investigation scientists.
IO 6. Review the process of obtaining clinical opinion in the programme.
IO 7. Reassure the workforce.
IO 8. Explore leadership development and coaching to foster a culture of support and where staff feel safe to challenge. IO 9. Evaluate and reflect upon the training programme.
IO 10. Explore ways the senior team can develop their own understanding of safety/ investigation/ human factors science. IO 11. Focus on quality.
IO 12. Taking the opportunity to learn.”

Alongside the operational disruption, the Benson report also noted cultural problems.

NHSE/I has drawn a ludicrous veil over these, as if people cannot deduce what happened from everything else that has come into the public domain since.

Here is a particularly absurd passage, which nevertheless flags bullying and intimidation:

“Culture

The structure, purpose and challenges of the maternity programme have driven a cultural identity which fosters pride in the combined aim to improve maternity services in England. The 14 regional teams provide individual investigators with a secure base from which they derive operational and emotional support and resilience.

Investigators reported:

• The programme structure and a ‘[Redacted]’ attitude cultivates a sense of oppression and control.
• Significant numbers (>20) of investigators openly reported either feeling bullied themselves or having knowledge of other people who had been bullied by staff more senior to themselves.
• Others (>30) recognised pressure which at times resembled bullying.
• They largely attributed this to the pressure being placed upon their direct line managers to, ‘[Redacted]’ of reports.
• Many investigators (>30) talked about feeling they could not challenge what was described as ‘Redacted’, which encouraged ‘Redacted’ attitudes towards investigations contrasting with the just culture they had been trained (at Cranfield) to adopt.
• Job satisfaction is significantly affected by this and recent messages from the senior team that unless the backlog is cleared by November 2020 ‘[Redacted]’.
• HSIB staff from across the whole organisations raised concerns that the ‘’[Redacted]’.

Matters were clearly serious as the review report noted:

“10.7. Reassure the workforce

Investigators feel insecure in their jobs and a significant number report they are considering or actively looking to leave HSIB because they feel their job is not secure.
This is something which has intensified over the period of the evaluation largely because of the pressure to reduce the backlog of reports.

[Redacted]

There is an opportunity to improve the wellbeing of the workforce and retention by offering reassurance about the methods being taken to reduce the backlog of reports.”

It appears that there were difficulties with whistleblowing, but as NHS Improvement have placed a strategic fig leaf over the relevant passage, it is difficult to be sure:

“8. Explore leadership development and coaching to foster a culture of support where staff feel safe to challenge.

• [Redacted]

There is an opportunity for improving the culture within the programme and the retention of the workforce. Exploring leadership coaching.”

Freedom To Speak Up at NHS England/ Improvement and whistleblowing by HSIB staff to Speak Up Guardians

NHSE/I have an extraordinary internal whistleblowing policy, where “triage” of whistleblowing matters, that are not immediately resolved by Freedom To Speak Up Guardians, is handled by a steering committee which includes the NHSE/I General Counsel.

Is it me or does that scream “containment”?

NHSE/I has disclosed that there are “55 NHSE / I Freedom to Speak Up Guardians across almost all regions and directorates. These Guardians are made up of staff from various roles and various levels of seniority.”

NHSE/I has also indicated that since HSIB became operational, 15 cases have been opened with Freedom To Speak Up Guardians on HSIB staff.

It would appear that the HSIB executive team were given ample warning in 2020, through the findings of the Benson report, of serious cultural problems in at least some parts of the organisation.

But for whatever reason, HSIB’s leaders failed to effectively address these problems, necessitating the further King’s Fund review in 2021, by which time staff trust had been further eroded.

A sad and telling entry in the review action log of December 2020 is the section that declares action on culture change “complete”:

There are serious questions arising about the consistency and quality of HSIB’s maternity investigations. Have some HSIB maternity investigations failed to identify all contributory factors? It sounds from the disclosed Benson report, for all its avoidance of hard data and detailed facts, that some investigation reports were defective and did not reveal the whole truth.

It is a pity that there is not a legal Duty of Candour for regulators, or that NHSE/I is compelled to own up to any families affected by any of these failures of HSIB maternity investigations. It is too awful to contemplate the abuse of trust. That harmed families put their trust in an independent investigation process which in some cases was not actually sound, and they may not have been told yet that this was so. And all the while, a former Secretary of State posed as a maternity safety champion, whilst strong arming a small safety agency to expand unsafely, for political gain and soundbites. And all the while he failed to implement the MidStaffs core recommendation on ensuring safe staffing for the NHS.

As Donna Ockenden who investigated the maternity failings as Shrewsbury and Telford Hospital NHS Trust has pointed out: “Maternity services have been underfunded for more than a decade so it will take time to get to where we need to.”

And we have yet to see if there are any other HSIB reviews that NHS Improvement has failed to disclose.

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