Previously suppressed sections of the Benson HSIB report reveal threats to jobs, resignations and fears of reprisal

Dr Minh Alexander retired consultant psychiatrist, 27 April 2023

On 20 April 2023 the principal author of a HSIB report appeared courageously at the current NHS England Employment Tribunal at Reading as a witness for the claimant.

She spoke to and expanded on her findings from a 2020 internal review of the HSIB maternity investigation programme, which assessed programme efficiency and quality of investigation reports.

HSIB’s Chief Investigator Keith Conradi asked her to undertake this review in her then capacity as Acting Head of Investigation Education, Learning and Standards.

She led the 2020 review, working with two other colleagues.

They found a number of disturbing shortcomings in the regionally based HSIB maternity programme, including issues of bullying.

In her witness statement to the Employment Tribunal, she corroborated the claimant’s report of being victimised for raising concerns about HSIB’s maternity investigations. She gave evidence of a recognisable pattern of bullying in the organisation, that other staff had also reported after raising concerns.

In response to questions from Tribunal members, she observed that the claimant had been bullied to the point of being “traumatised”.

I will leave it to the media to report in more detail about these matters.

The issue that I wish to highlight is from documents disclosed in the Tribunal bundle.

Until now, NHS England had only released a redacted copy of the 2020 Benson report, which was provided under FOI in May 2022.

Contained in the current ET bundle are two un-redacted slides from the report, revealing some of what had hitherto been concealed:

  • Reported messages from the HSIB senior team to the HSIB workforce that “jobs will be threatened” if the maternity report backlog was not cleared, and that staff were consequently pressured to produce reports
  • Some staff had left HSIB because they felt compromised by the investigation process, but were also fearful of reprisal by HSIB once they were back in clinical roles

How can there be just culture if investigators are coerced into hurried investigations that fail to fairly identify all contributory factors?

The slides support the claimant’s contentions that there was an unsafe management drive to churn out investigation reports at a cost to thoroughness.

It is troubling that the message about the threat to jobs and pressure to churn out reports reportedly came from the HSIB senior team.

Would that explain Keith Conradi/ HSIB’s later reluctance to deal properly with the claimant’s whistleblowing about management pressure to produce reports and poor handling of maternity investigations, as found by the Susan Newton investigation?

Was there a conflict of interest?

If Conradi was ultimately responsible for any undue, top down pressure to clear the maternity report backlog without proper regard for safety, he should have recused himself from dealing with the claimant’s case.

It may be relevant to revisit the letter of recommendation from Jeremy Hunt of 26 May 2016 to PACAC:

The two slides from the ET bundle, along with the redacted versions for comparison, are provided below.


The content of this slide is copied from the ET bundle. There was highlighting on the slide, which is reproduced below.


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:

Significant numbers (>20) voluntarily 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 manager to reduce the backlog’ of reports

Many investigators (>30) talked about feeling they would not challenge what was described as ‘clinical dogma’, which encouraged ‘blamey 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 – ‘jobs will be threatened’ (MI)

HSIB staff from across the whole organisation raised concerns that the culture within the maternity programme could tarnish the reputation of the whole organisation’

This is the redacted version of this slide which appeared in the Benson report


The content of this slide is copied from the ET bundle. There was highlighting on the slide, which is reproduced below.

10.8 Explore leadership development and coaching to foster a culture of support where staff feel safe to challenge
Staff talked about feeling ‘bullied’ or others being ‘bullied’ or targeted if they ‘put their head above the parapet and challenge the senior team’
Staff were not asked about being bullied, some staff volunteered this information
The evaluation team recognise this has not been explored across the whole maternity structure
Staff, who have left HSIB because they felt the investigation process compromised their integrity, reported fear of reprisal from the HSIB maternity programme senior management once they were working back in a clinical environment

This is the redacted version of this slide which appeared in the Benson report


Finally revealed: The suppressed Susan Newton report on whistleblowing governance at HSIB/ NHS England

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

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

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s