Slow and incomplete maternity investigations: Death of baby Theo Young and Coroner’s serious criticisms of HSIB

Dr Minh Alexander retired consultant psychiatrist 24 April 2023


The HSIB maternity investigation programme was commenced as a political vanity project, against professional advice, under Jeremy Hunt’s tenure as Health Secretary.

Its ambitious brief was to replace local NHS maternity investigations, a huge task.

These are the legal directions for establishment of the programme in 2018, which emphasised unequivocally that HSIB investigations must “identify all contributory factors that led to that outcome”: 

The National Health Service Trust Development Authority (Healthcare Safety Investigation Branch) (Additional Investigatory Functions in respect of Maternity Cases) Directions 2018

HSIB a tiny, centralised specialist investigative agency mushroomed rapidly into a sprawling body with maternity branches based in the regions, that operated on different directions.

Who could have predicted that things would go wrong?

It is thanks to HSIB maternity whistleblowers that the public became aware of serious deficiencies in what should have been a vital safety service.

Internal whistleblowing at HSIB and NHS England ultimately led to an announcement that HSIB had been stripped of its maternity investigations, but with little transparency about the issues.

With great reluctance, NHS England later released some of the relevant reviews about these matters, which it had previously suppressed from public view:

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

More secret HSIB reports and failures of HSIB maternity investigations

Leadership failures and bullying culture were issues identified by reviewers.

Keith Conradi the controversial HSIB Chief Investigator’s departure was announced in November 2021 after the initial findings of one of these reviews were shared.

In a later interview he claimed that senior leadership at NHS England did not prioritise patient safety, in a seeming attempt to justify his own position.

Slow and incomplete HSIB maternity investigations, Death of baby Theo Young and Coroner’s serious criticisms of HSIB

In a current Employment Tribunal case against NHS England, the claimant said in oral evidence last week, that she was concerned both that HSIB was not turning investigations around fast enough and that management tried to restrict the scope of her investigations.

This was set against the 2018 HSIB directions which required investigators to identify ALL contributory factors.

The principal author of the internal Benson report on deficiencies of the HSIB maternity investigation programme appeared as a witness for the claimant, and gave supporting testimony.

A corroborating piece of information about the general concerns about HSIB’s maternity investigations already lies on the public record.

This is the findings from the 2020 inquest of baby Theo Young who died under the care of Surrey and Sussex Healthcare NHS Trust (SASH) in 2018 (not to be confused with the well publicised and also avoidable death of baby Theo Ellis at Frimley).

The Surrey Coroner, Karen Henderson, found that baby Theo died of perinatal hypoxia contributed to by neglect. He was allocated to an inexperienced midwife who did not recognise a pathological CTG reading and did not escalate to a more senior midwife or obstetrician, and he would probably have survived if help had been sought appropriately.

Notably, the coroner was very concerned about the actions of HSIB in this case and issued a Prevention of Future Deaths notice that solely related to the actions of HSIB in forbidding the trust to undertake a local investigation whilst exceeding its own target six month target, and not producing an investigation report until eighteen months later, which was substandard.

Prevention of Future Deaths report baby Theo Benjamin Young April 2020 Ref 0094 20


The MATTERS OF CONCERN are in relation to the role of the HSIB in their conduct, investigation and conclusion: 

1. The HSIB specifically requested the Trust not to undertake their own investigation effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths.

2. HSIB indicated to the Trust at the outset that their investigation would take approximately six months which is highly likely to delay the introduction of any immediate necessary measures by the Trust to prevent further deaths. 

3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted.”

It is quite something that an agency that is supposed to help prevent deaths was found to have obstructed learning and so endangered the public.

The coroner added in her PFD notice that she had other concerns about HSIB which did not fall under PFD remit, but which she would be taking up.

“Other matters were brought to the attention of the court outside of PFD matters which raise considerable concern as to the role and actions of HSIB which I will deal with in a letter to them in due course and will be shared with other relevant bodies.”

Keith Conradi replied on behalf of HSIB to the Coroner’s PFD in what did not appear in my opinion to an especially conciliatory tone and did not demonstrate measurable learning with respect to evidence of improvement.

HSIB made similar comments to the Health Service Journal.

The Department of Health through Nadine Dorries also replied but did not appear to take any effective action to hold HSIB to account.

These are the various organisational responses to the Surrey Coroner’s PFD on baby Theo Young:

SASH response to PFD on baby Theo Young

Keith Conradi HSIB response to PFD on baby Theo Young

Nadine Dorries DHSC response to PFD on baby Theo Young

I have written to Ted Baker former CQC Chief Inspector of Hospitals, now HSIB Chair, (who missed an opportunity to set matters right in the Shyam Kumar whistleblowing affair, which was followed by Mr Kumar lodging a successful ET against CQC).

I have asked Ted Baker about what evidence HSIB subsequently tracked on the timeliness of its investigations, such as how soon after incidents did interviews with involved staff take place.

I have also asked him about the “other matters” that caused the Coroner considerable concern.

Correspondence Ted Baker 23 & 24 April 2023 HSIB Chair re tracking timeliness of maternity investigations and Coroner’s concerns arising from PFD baby Theo Young

The Employment Tribunal against NHS England continues, with substantial media presence.

The Claimant’s evidence is expected to resume today.

This is a comment left anonymously under the article in HSJ about the Coroner’s criticisms of HSIB in the Theo Young case. It seems that other trusts, unsurprisingly, may have had similar misgivings, lending further credence to the concerns currently being aired in the NHS England ET:


NHS England appears to claim that tampering with medical records is not illegal. The legal minefield and what whistleblowing disclosures are legally “protected”?

NHS England appears to claim that tampering with medical records is not illegal (II). Or an apparent failure of organisational memory

Prescribed Persons or the Pretence of PIDA. How UK whistleblowers are ignored

NHS England found guilty of whistleblower detriment and Race victimisation against Ms Cox. Wilful blindness & power abuse at the heart of the NHS

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

More secret HSIB reports and failures of HSIB maternity investigations

HSIB has sent 152 letters of concern to NHS trusts about maternity safety, including 15 letters to one trust

Replacing the Public Interest Disclosure Act (PIDA)

What could a new whistleblowing law look like? A discussion document

2 thoughts on “Slow and incomplete maternity investigations: Death of baby Theo Young and Coroner’s serious criticisms of HSIB

  1. It doesn’t look as if much is set to improve at HSIB, having been [populated with the CQC’s former senior executives ; Ted Baker – former CQC Chief Inspector of Hospitals – now HSIB Chair, AND Rosie Benneyworth, formerly CQC Chief inspector of Primary medical services – now HSIB Chief Investigator – replacing Keith Conradi,
    We all know how they performed at the CQC – so it looks as if things can only get worse at HSIB, as it is populated with former CQC executives, undoubtedly bringing their toxic culture along with them.

    Liked by 1 person

  2. Regrettably, it seems organisations and their progeny are created for the benefit of their senior employees and politicians and not necessarily for the benefit of their ‘customers,’ patients or victims.

    Liked by 1 person

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