I am really shocked by the findings of this review and feel deeply sorry for those who have had such poor experiences working for HSIB. There is absolutely no justification for the type of discriminatory and unprofessional behaviour described in this report. It is simply unacceptable and senior leaders in the organisation must take responsibility for immediate change.
HSIB was established as a new organisation – from scratch – in 2017. It quickly brought together an eclectic mix of technical experts from a wide range of professional backgrounds, including healthcare, commercial and military aviation, education, the police and human factors. The expectations of delivery from the outset were very high and the challenges associated with leading a group of senior experts with such a diverse range of experiences; professional norms; and approaches to leadership were significantly underestimated.
The Maternity Investigation Programme massively increased the workload and operational complexity of the Branch at a very early stage in its development. The programme was a significant departure from its core purpose of intelligence gathering and undertaking national investigations into a small number of the highest risk systemic issues ever year. Many of us opposed the Programme from outset, but without statutory independence, the directions from the Secretary of State were irresistible. This is why it is so important that amendments are made to the legislation currently going through Parliament to limit such powers of direction in the future.
Furthermore, as the report clearly identifies, the macro conditions that HSIB has been operating within have been complex and uncertain. The legislation to put the organisation on a statutory footing – which included arrangements for an independent non-executive Chair and Board – have been “just around the corner” for several years now, and even now are potentially still a year or more away. Increasingly unclear governance arrangements and confused lines of accountability have made high quality, independent oversight and scrutiny almost impossible.
The Advisory Panel, which has no formal governance role, repeatedly raised concerns about the effects of a lack of independent external scrutiny and assurance. We wrote to the DHSC in May 2019, and I have reflected these concerns in both annual reviews that I have authored since becoming Chair of the Advisory Panel in the same year.
HSIB is doing really excellent and innovative work in so many domains – from family engagement to investigation science education to ground-breaking principles for strategic partnerships with citizens. It therefore vital for the future that the issues identified in this review are tackled with vigour and commitment.
As the organisation becomes a fully independent statutory body, it must actively pursue a more inclusive and collaborative working culture, characterised by civility, support and a deep appreciation of the value of diversity. HSIB staff do very tough work and they must be properly coached and supported in that endeavour.
HSIB must now directly face the issues identified in this report, and work constructively and collaboratively with those most affected to implement the recommendations without delay. Although the Advisory Panel has an incredibly narrow remit, and I have no formal authority, I will certainly be using my influence to call for independent governance arrangements to be put in place without delay.
Prof. Murray Anderson-Wallace
Chair, HSIB Advisory Panel
Notes: The HSIB Advisory Panel was established in 2016 under section 9 (3) of the directions from the Secretary of State that formed HSIB as a division of NHS Improvement. Our core role under these directions is to ensure the independence of HSIB investigation processes and reports whilst hosted by NHS Improvement and sponsored by the DHSC.
The Panel brings together a group of independent people with a unique blend of expertise in the fields of patient and family advocacy, citizen leadership, clinical practice, healthcare policy, education and ethics, and professional investigation in other industries. The Panel has a purely Advisory function with no formal governance role or responsibilities.