Public Administration and Constitutional Affairs Committee
Oral evidence: Pre-appointment hearing: Chief Investigator, Healthcare Safety Investigation Branch, HC 96
Tuesday 7 June 2016
Ordered by the House of Commons to be published on 7 June 2016
Members present: Mr Bernard Jenkin (Chair), Paul Flynn, Kelvin Hopkins, Mr David Jones, Gerald Jones, Mr Turner.
Questions 1 - 75
Examination of Witnesses
Witness: Keith Conradi, Chief Inspector of Air Accidents, Air Accidents Investigation Branch, gave evidence.
Q1 Chair: May I welcome our pre-appointee to this pre-appointment hearing for the Chief Investigator of the new Healthcare Safety Investigation Branch of the Department of Health? Please could you introduce yourself for the record?
Keith Conradi: Yes, Keith Conradi.
Q2 Chair: You have of course been a witness before this Committee some 18 months ago when we were constructing our proposals, which the Government are in the process of adopting. I think I am right in saying that you also served on the Expert Advisory Group, which sat for about a year, looking at our proposals and working on them.
Keith Conradi: Yes.
Chair: Could I suggest—we do not want to keep you for too long—that we will ask short and crisp questions and if you give short and crisp answers, that would help us, otherwise I may shorten your answer for you if you go on for too long. Question 1, Mr Jones.
Q3 Mr David Jones: Good morning, Mr Conradi. I see that you have some 30 years’ experience of the aviation industry. Have you any experience of the NHS and the healthcare sector?
Keith Conradi: No. The only experience I have is sitting on the Expert Advisory Group and the evidence that I have given previously to this Committee.
Q4 Mr David Jones: You have of course been the Chief Inspector of the Air Accidents Investigation Branch. To what extent would you say that that experience will be relevant to the role of Chief Investigator for the Healthcare Safety Investigation Branch?
Keith Conradi: I think it will be hugely relevant. What I will bring is a professional investigation into the Healthcare Safety Investigation Branch, which has been developed over the last 14 years with the Air Accident Investigation Branch.
Q5 Mr David Jones: To what extent would you say that your experience in the aviation sector is transferable, if you like, to the proposed role of Chief Inspector of the HSIB?
Keith Conradi: I do not think it is so much the fact that it is aviation, it is a fundamental philosophy of the way we do investigations, it is the no-blame approach that has been prevalent in aviation for many, many years. I think that is probably the most important thing that I will be able to bring into this role.
Q6 Mr David Jones: Could you expand on that, please?
Keith Conradi: Aviation has grown up with a culture of investigations that are just there to improve flight safety, to learn from previous accidents and serious incidents and we spend our whole time investigating and reporting on those events. We do not apportion any blame or liability and that is an area, I understand, that could be hugely beneficial when coming into the healthcare industry.
Q7 Mr David Jones: What would you say would be the principal components of an excellent clinical investigation?
Keith Conradi: I think it is having people who are totally impartial and are independent of anything to do with the area in which they are investigating. I think they need to be experts in gathering facts, gathering all the evidence, analysing that evidence and then putting together sound safety recommendations, which are required to be answered by the addressee. By “answered” I mean they can accept or refuse them, but they need to give reasons as to why they have done that.
Q8 Mr David Jones: So the team that you assemble would be crucial in connection with an excellent clinical investigation?
Keith Conradi: Indeed, yes.
Q9 Mr David Jones: If you are appointed, you will be responsible for establishing the organisation so that it is ready to commence its functions in April of next year. What experience do you have of setting up a new organisation such as that?
Keith Conradi: I have not set an organisation up totally from scratch, but what I have done is made significant changes within my own organisation. I have had to recruit many people during my time there. I have changed the working practices of some of the things we do and I have also been heavily involved in scoping national legislation, which we are currently changing in the aviation world, but also European legislation, which we are also subject to. I think all those experiences will be beneficial in setting the HSIB up in this very challenging time that we have available.
Q10 Mr David Jones: How would you set about establishing that new team, putting it together?
Keith Conradi: I need to take soundings from within the industry of what is available to me on a practical sort of service, where I can go, but primarily I need to design the organisation, I need to then go out and recruit and also train, and I think training is a fundamental part of what needs to be done. Getting all that done by April is going to be incredibly demanding. There may be opportunities to second people who already have investigative experience, but these are things that I need to learn from the people that I will be working with in the industry.
Q11 Mr David Jones: The people that you recruit to this new team, I guess some of them would have to have relevant clinical experience, but presumably others might have different qualifications that might be transferable. Have you considered that?
Keith Conradi: I certainly absolutely know that there is a need for clinical experience, so that will be a part of the teams that are brought together. I also think an experience that will be needed is human factor type investigations. The vast majority of the events that we will be investigating will be really human factors at the core of what has gone wrong, so I will be looking in that direction, and I will also be looking for those who have had no-blame investigation experience as well, who will be able to bring some of that philosophy, like myself, to the organisation.
Q12 Chair: Mr Conradi, why did you apply for this job?
Keith Conradi: I have been in charge of the AAIB for six years and to quote a sports philosophy, it is kind of marginal gains in aviation, it is well set, it is running nicely. I think there is an opportunity here to make some big fundamental changes. Having sat on the Expert Advisory Group, I can see just how much is transferable from the no-blame investigations that we currently do into the healthcare industry. I would very much want to be a part of that in leading that new organisation.
Q13 Chair: You are an aviator, you are a pilot, so you went into safety investigation in aviation with that absolute hands-on experience and training as a pilot. Why isn’t it a handicap for you to take on this responsibility when you have absolutely nil clinical expertise or experience?
Keith Conradi: When you look at the investigations that have taken place previously within healthcare, none of them, as far as I am aware, have come with this type of different approach, this real no-blame investigation. I think if you continue to do the same things that you have always done, you will get the same results, so by bringing in a completely new type of investigation there is great scope for making a difference. I think the fact that I have had no healthcare experience is beneficial in a way, because I will be looking at these reports more from a layperson status, so as I read through them, I will be able to say, “Does that make sense or doesn’t that make sense?” We will have access to all the expertise we need to ensure that technically the reports are accurate, but it is the other side, it is the conclusions and the safety recommendations where we can make a big difference.
Q14 Chair: So in terms of ensuring the accuracy of your reports, an AAIB investigation arrives with an aviator, an aeronautical engineer and a human factors analyst, broadly. How will you apply the equivalent skills to a clinical incident investigation and what would those skills be?
Keith Conradi: We will have clinicians as part of the team, we will have human factors, as you have mentioned, as part of the team and we will have investigation specialists as part of the team. Now, they will then decide when they go into a particular event they are looking at what expertise they then need to access. It could be that we have nominated experts in particular different areas that we can—
Q15 Chair: Such as?
Keith Conradi: Such as any of the areas. It could be anything from neurosurgery to physiotherapy. I don’t think it really matters, but the fact is that we can have access to those who are best-placed to give us the information. In aviation, we are not the experts in the areas. Although I fly an Airbus A320, if we want a technical investigation on that, we go to the manufacturer, we go to the chief test pilot or to anybody who can provide the expertise that we need. I do not see any reason why healthcare should be any different.
Q16 Chair: In terms of building up the organisation, how big is AAIB?
Keith Conradi: Fifty-five people.
Q17 Chair: It is initially suggested that HSIB should be doing about 30 investigations a year. How many people do you think you will need for that?
Keith Conradi: I should think about half of that, 25 to 30.
Q18 Chair: How quickly will this grow and how will you decide how to grow the organisation?
Keith Conradi: My initial thoughts are that we need to get a team together fairly quickly, because one of the ways that we can demonstrate that this works is by doing some investigations early on, as soon as we can. I will be looking to get a team in place and then grow from there, but bear in mind it is not just investigators, we will also need a support team, we are going to need comms, publications, IT, these people who will set ourselves up as well. Part of, if you like, being independent is that we have our own support staff who are an absolutely vital part of the investigation.
Q19 Chair: How equivalent to AAIB is that concept?
Keith Conradi: That is exactly the way that we run it. We have to do more with AAIB because we have hangars and wreckage and all those bits and pieces, but fundamentally we have our own support staff.
Q20 Kelvin Hopkins: Mr Conradi, how would you explain the safe space principle?
Keith Conradi: The safe space principle is the opportunity for anybody to come to the investigation team and provide a confidential statement on anything that has happened, anything that they wish to tell us, with the knowledge that we will do our best to keep that secure, but it is not absolute.
Q21 Kelvin Hopkins: That is interesting, because there will obviously be concerns, but how would you justify this safe space to patients and families who are concerned about the lack of openness in investigations?
Keith Conradi: We have to remember we are doing this investigation to learn from what has happened, so if somebody comes to us and they explain what they did, we will use that—although we will not release that specific statement—information to construct our report, so the information that has been given will go out in the final report so that learning can take place. In my experience in aviation, the most important thing that families tend to want is to know that nobody else is going to suffer the same heartache that they have. If something has changed or there are recommendations to improve things, that gives them enormous satisfaction. So I think the fact that we can use this information to provide that will be hugely beneficial to most of the families that we deal with.
Q22 Kelvin Hopkins: The information in your report will be non-attributable, presumably; is that how it works?
Keith Conradi: Yes. It will be anonymous information, but will go to explain what happened and how we can improve things.
Q23 Kelvin Hopkins: The Expert Advisory Group has recommended that HSIB should embody the “duty of candour” in its dealings with patients and families involved in the investigations. How do you intend to balance the need to be open with patients and families affected by clinical incidents with the demands of the safe space principle?
Keith Conradi: We need to understand that we are not necessarily the only investigation in town. We are doing this investigation from a safety perspective, but that does not stop contact between anybody in the industry and patients and families and potentially any other investigation that may take place. We are quite used to, in my world, doing parallel investigations with judicial authorities. We do not have anything to do with theirs and vice versa, but I think ours is but one of an investigation that may take place.
Q24 Kelvin Hopkins: Will this safe space principle be explained to patients at an early stage so they do understand how it all works?
Keith Conradi: That is crucially important. I think managing expectations, early engagements with patients and families to explain that this is a no-blame investigation and to make them understand what the aim of this investigation is is all-important, yes.
Q25 Chair: Moving on, question 4, please. Sorry, on the safe space principle, let me just ask one other supplementary, which is this was controversial in the EAG, wasn’t it?
Keith Conradi: Yes.
Q26 Chair: How do you explain to people who fear a cover-up that you need this safe space?
Keith Conradi: I explain it by saying that nearly everybody comes to work not intending to do harm, therefore when things happen there is usually a reason behind it and it is understanding why something happened. If this safe space allows people to talk to us freely, we can take that information and translate it into positive safety action and recommendations and then it becomes a hugely worthwhile experience. On those extreme cases where there is obvious criminality, that is where, if you like, another investigation will take place and resolve that issue, but that is not for us.
Q27 Chair: But a lot of the argument is about professional competence and possible negligence, because what might be just inadvertent incompetence becomes negligence somewhere in the spectrum and people feel that people should be accountable for that incompetence or negligence. How are people made accountable if nobody is ever going to know what they have told you?
Keith Conradi: Just because they have talked to us, it doesn’t stop somebody else taking it in a different direction as well. As I say, there could be a parallel investigation. Some families will not be satisfied with our pure learning that has come from this, some may want more. Nothing that we do will stop them from doing that, it is just that we go in with a specific aim to improve safety.
Q28 Chair: So it is very important to understand that the safe space that you envisage does not block anything that currently takes place at the moment, such as the duty of candour, such as any court proceedings or legal actions or anything like that?
Keith Conradi: Absolutely. It is totally different, and if there is another investigation, it will not be using the information that we have, it will be getting its own investigation.
Q29 Chair: So your investigations will not be replacing any existing remedy that exists?
Keith Conradi: Not necessarily. I see it as a totally different area that we run in.
Q30 Mr David Jones: Just pursuing that, clearly while the sort of investigation that you envisage as Chief Inspector of HSIB is similar, to a large extent, to your previous experience, isn’t the difference that here you are frequently dealing with laypeople who have no professional understanding of the matters that you are investigating, whereas of course as part of the Accident Branch, you are dealing always with aviation professionals? Isn’t it important not only to have a no-blame approach, but also to publicise, to make the public aware of why that approach is necessary and why you intend to pursue that?
Keith Conradi: I agree. I think we should make the whole methodology of what we are doing fully public. In fact, we are going to be writing and publishing the investigation principles under which we work. But, in fact, it is not that far different sometimes from aviation in that we are often having to explain very technical, complex investigations to families who are effectively laypeople in many aspects. So throughout the investigation, at certain stages we brief families on where we are at the investigations. I see exactly the same principle happening with the HSIB.
Q31 Kelvin Hopkins: It strikes me that one of the most important features of your organisation to which you will be appointed is that the people coming face-to-face with patients should deal with them in an intelligent, calm and sympathetic way, because in my experience as a politician, when people come to you, they are troubled. If you can make them feel more comfortable, then you are helping them. If you make them feel less comfortable, you are not helping them. Would you agree that that sort of training, if you like, in dealing with people directly is very important?
Keith Conradi: I do agree with that. We often have to meet families at aviation accident sites and we try to take that approach to calming down and explaining what we are all about in a very unemotional and calm way. Yes, I agree.
Q32 Paul Flynn: If I recall your previous evidence correctly, I believe that your interest in this matter arose in the fact that you were appalled by the inadequacy of an investigation into a death in the health service, compared to the thoroughness of deaths that occur in accidents in aircraft. Is this right?
Keith Conradi: I certainly know of cases in healthcare where there seems to be, yes, not a thorough investigation at all.
Q33 Paul Flynn: What I am trying to get at is I believe it was a personal experience. I do not necessarily want to go into the details of it, but I am asking whether someone with a very powerful personal experience in here would have the right objectivity to investigate other accidents without having the anger and grief against a failure in the past to distort their judgment.
Keith Conradi: I certainly do not have any personal experiences. I do think I can bring almost a dispassionate attitude to this, which is what I look for in the investigators, somebody who is not emotionally driven and can understand the impartiality that needs to go into an investigation.
Q34 Paul Flynn: You are going into a world where there are very powerful bodies, the BMA, the Royal College of Surgeons, the Royal College of Nurses, the Royal of College of Midwives, and unfortunately, most important of all, the most powerful lobbying group of all is the pharmaceutical industry, who all have their own influences and are used to getting their own way in these matters. How do you think you will come in, as a newcomer, as a new broom, to reform the system?
Keith Conradi: I do not see us necessarily reforming the system, I see us being part of the overall safety system and trying to improve things in that aspect. But I think what is crucial from what you are saying is that we are independent and we are perceived to be independent and we make our recommendations to those who are best able to make the changes. That could be anybody, not necessarily just regulators, it could be anybody out there.
Q35 Paul Flynn: Your evidence and your role in the body that set up this appointment and designed the job was a considerable one. You made a major impact on this Committee last time, but would there be a fair criticism that you have designed a job for yourself to fill?
Keith Conradi: I think you could suggest that. I certainly had no real thoughts of doing this until I started to sit on the Expert Advisory Group and it became clear what aviation could offer, so I am pretty neutral in the fact that I can offer something. I did not really have anything to do with scoping the job out, more the branch itself.
Q36 Paul Flynn: This would be a bold appointment and it is an attempt to graft on to the health service a system that works very well in another area, but these grafts do not always work. Do you think it is sensible to do this, where you are investigating a small number of incidents, a tiny number of incidents involving accidents with aircraft, with the 30 incidents, which are a sample of thousands of incidents that take place in the health service every year? There is a huge difference in scale.
Keith Conradi: There is a huge difference in scale. I know there are differences with aviation and healthcare and that is one of the major ones. But one of the aims of the HSIB is to set up, if you like, some standards for all the local trusts and investigation groups, to bring those up to a consistent standard. I see that becoming a major part of what HSIB does, because you are right, we cannot investigate individual deaths all over the place. It is only going to be major thematic studies that HSIB will investigate itself.
Q37 Paul Flynn: If I was travelling on an Airbus tomorrow and the pilot told me he did not have a pilot’s licence but he was a very good doctor, I might have qualms. Aren’t you in the same position in reverse?
Keith Conradi: But I am not going out there to carry out any operations, I am going there to carry out investigations and that is what I am professional at doing.
Q38 Paul Flynn: How do you think the HSIB would promote trust in clinical incident investigations that take place? It is a tiny sample you are taking, but can you really make a difference, do you think, to the whole body of unhappiness there is about the level of investigations into tragedies in the health service?
Keith Conradi: I think we can. I look at the investigations that have taken place recently and I look at Morecambe Bay, for instance, which I think we could take that, that is the sort of thing that I could see HSIB doing, and we could make a big difference with that. On those big events, yes, I absolutely see that we can make a difference, and then at the same time by bringing all the others up and, if you like, making sure that those standards are set in stone, I think you start to change the culture of what has gone on. I think that is one of the big differences between healthcare and aviation. Aviation has grown up with that culture. There is a need, I understand, to change that within healthcare.
Paul Flynn: I am grateful to you, thank you.
Q39 Chair: There is a danger with expectation, isn’t there, because unlike aviation, which is a very, very safe industry and operates in a kind of closed environment in terms of sick people do not generally travel on aircraft, aircraft do not fly if it is not safe to fly? A complete opposite in the health service, we are dealing with sick and dying people and a lot of operations undertaken are risky, therefore there are a huge number of incidents. How are you going to avoid just being a kind of gadfly in this vast system, in which people die all the time, because that is part of healthcare?
Keith Conradi: It will be important to set out some criteria for the events that HSIB will undertake themselves. I do not know what the answer is to that at the moment. It is more themed investigations, I think, than aviation. We are looking not at one-off type events, but when we can see sort of a pattern starting to emerge. I think there are lots of challenges there and looking at even the way data is collected and analysed is an important part of that. I will be looking to understand what has happened previously, to understand where we need to go in the future.
Q40 Chair: How will you engage all those organisations that represent interests in the health service, like the pharmaceutical industry and the BMA or the General Medical Council or the Royal College of Surgeons, without being unduly influenced by them?
Keith Conradi: One of the things I wanted to do in the early stages is to, if you like, go out and talk to the more cynical aspects of the industry and explain to them what this is about, but also listen to them and understand where they see the difficulties. That will be useful in helping me focus on, “Okay, which areas may we be looking to do some of these events and how are we going to be achieve our safety action?”
Q41 Chair: Do aircraft manufacturers try to influence your investigations and what do you do about it?
Keith Conradi: Not overtly, they do not try to influence.
Chair: That means yes, they do.
Keith Conradi: I mean behind the scenes, yes, they have. Obviously there are commercial aspects.
Chair: What do you do about it?
Keith Conradi: We collect good evidence, we collect good data and we listen to what they have to say. We will use them as advisors to the investigation, because we need sometimes their expertise, but at the end of the day, when we have decided on safety recommendations, they will often go to the manufacturer and we give them that opportunity, we make them to them. We have had some pretty robust arguments at the later stages of an investigation when we are forming these recommendations. The key thing with our industry—and this is what I would like to see in the future—is that they are required to respond to these safety recommendations. They can say no, but they must give a reason why they do not think that that needs to happen.
Q42 Mr Turner: What steps are necessary to safeguard the independence of HSIB and the office of Chief Inspector?
Keith Conradi: I think there are several. I do think that legislation is required. I think the directions give some framework, but I firmly believe that legislation is the only real way to protect the independence. It is important that the reports we produce are signed off by me and submitted to the Secretary of State. I would not want to see anybody else in that line. I also think that the location of the headquarters is important, perceptually as much as anything else, and I certainly would not want it to be in NHS Improvement or probably attached to any existing healthcare. There may be some benefits from collocating with other accident branches to demonstrate this is separate from existing healthcare.
Q43 Mr Turner: Can you give an example of when you have previously had to act independently when subject to pressures from Ministers, the media, those affected by accidents?
Keith Conradi: We had a helicopter accident not far from here that hit the tower in Vauxhall a couple of years ago, which obviously got a lot of media attention, and we made several recommendations to the Department for Transport regarding building regulations in airspace and different things like that, which I think demonstrates that we can be robust and push back against even those who are providing our pay and rations. We treat them, in that respect, like everybody else when we make recommendations to them.
Q44 Mr Turner: Something appears to me to have two responses: there are those large disasters, if you like, and there is maintaining the lower down but none the less important problems, that individual hospitals perhaps are doing the same sort of thing, and you are bringing those forward, I suspect, am I right? Are you sure you have the time to do both equally well?
Keith Conradi: I do not know as yet exactly how it will work, but I do see—and it is in the aims there, in the directions—that raising the level of local investigations is an important part of what goes on here, and I do think that is absolutely the right way. I think even a small group can set standards, can set recommended practices for others to be able to follow and that can then be checked and audited against to ensure that that is what is happening. But more than that, and I think perhaps this is what you are saying, is gathering the intelligence, if you like, from almost the disparate groups and trying to see, “Does that fit? Does that require a major investigation to go in?” and that will develop over time, but I think that will take some time to work to its optimum.
Q45 Mr Turner: What do you mean by “time”?
Keith Conradi: It is important to get some teams set up so that we can do some full HSIB investigations, and once those are up and running, then as we recruit more people and build the organisation, then we will start to go out and discuss the training and the standards that will come on thereafter. I would like to think that we would have good standards and recommended practices within 18 months or so of the start-up so that we can then get others to follow.
Q46 Mr Turner: Finally, the Secretary of State, Jeremy Hunt, recently stated in a March 2016 speech that he had asked HSIB to consider initially focusing on maternal and neonatal mortality investigations. How will you decide what HSIB should do with its limited capacity?
Keith Conradi: We will need to set certain criteria for the investigations that HSIB does. I do not know what those will be as yet, but I see once I have a senior management team together within the organisation that we will meet on a regular basis and extraordinarily as required to discuss information that is coming in and decide as a team which ones we are going to investigate. We will then publish that information, that we are going to investigate this and put an estimated timeline that will go with that as well.
Q47 Chair: How important is it that you choose yourself what to investigate?
Keith Conradi: Oh, I think it is crucial. I do not think there will be confidence in the system if we are just seen as somebody who is at the beck and call of anybody. It comes down to the independence again.
Q48 Chair: Why is it so important not to be part of NSHI?
Keith Conradi: Because a lot of the time we will be putting recommendations right in that direction. I mean, perception is so important, and if people think that we are one and the same, I do not think people will have any confidence or faith that we are really getting to the nub of the problem that is out there, so we must maintain that separation.
Q49 Chair: It is at the moment the Government’s policy that HSIB should be domiciled with NHSI. What are we to make of this disagreement between you and the Government?
Keith Conradi: At the moment I do not think that is the optimum model by any means, but I am pragmatic, and I think if we want to get this thing off the ground and going, we do need somewhere to start with. There is a budget out there, there is some logistic help and what I would like to do is get the whole thing moving, get a team together and then I think it is time to take stock and review and go, “Right, what is going on here? Is this the best place to be?” But I think that has to be done with legislation as well.
Q50 Chair: I was going to come to that. Why is underpinning legislation so important?
Keith Conradi: That sends out a clear message that this is not at anybody’s beck and call. We have some great wording in aviation: functionally independent, neither seek nor take instruction and unrestricted access to the investigation and control over the investigation. Those are the sort of words that I would be looking for to enshrine this branch as being able to do what it sees as the most important work in the safety investigation front.
Chair: That could not be clearer. Question 7, David Jones.
Q51 Mr David Jones: Mr Conradi, as Chief Investigator, you are going to have to work successfully with NHS England, with CCGs, NHS trusts and also with regulators such as NHSI and the CQC. Can you tell us how you would go about building those relationships?
Keith Conradi: Initially I need to go around and talk to those organisations themselves to familiarise myself with exactly what their roles are and where they come from. Then it is maintaining a working relationship with them. Independence doesn’t mean that we do not talk to the regulator, and as we build through an investigation, I would be wanting the regulators, the appropriate regulators, to have an involvement in that investigation because they are the ones who are best able to change whatever might need changing. I think, most importantly, rather than make safety recommendations at the end, I will be looking for the regulators to have taken safety action in the meantime, as it demonstrates that they are taking this seriously. We can then mention that in the report, that this has happened as a result, but I think that can only happen if we have a working relationship with the regulators during the investigation.
Q52 Mr David Jones: Do you envisage any particular difficulties in building relationships with NHSI?
Keith Conradi: I do not see why there should be, no.
Q53 Mr David Jones: Given the history of the establishment of HSIB?
Keith Conradi: We have clear directions set out. I have a clear idea of what I am after and I intend to go in exactly on that basis. The information that I have received is very much that they are open to this idea of independence and that I am pushing against an open door.
Q54 Mr David Jones: We have heard that the Department of Health envisages only about 30 investigations by HSIB per annum. How realistic do you consider that estimate to be?
Keith Conradi: I think it is difficult to say at the moment. You do not know what is around the corner and it is like any reactive organisation, there may be some times when there are much less and then there may be other times when we have a great deal more. We are going to have to be a little bit flexible and we are going to have to discuss and use the local investigations to decide at what point, if you like, we need to come in. There may be some subtle changes from year to year, depending on our workload.
Q55 Mr David Jones: Given the number of procedures, the number of treatments that are executed by the NHS every year, 30 does seem to be an extraordinarily small number.
Keith Conradi: I think we are only dealing with the tip of the iceberg when it comes to an actual HSIB investigation. It is the likes of Morecambe Bay that it would undertake. The vast majority will take place by the local investigation teams, which is why they need to be of a high standard.
Q56 Mr David Jones: As Chief Investigator, it would be your responsibility to define the investigation principles that would help determine which cases to investigate. How would you go about defining and developing those principles?
Keith Conradi: Again, I can bring a lot from my existing industry in the principles of investigation. We have a very mature document—which is accepted worldwide—from the International Civil Aviation Organization, which runs through in fact just that, investigation principles, who can take part, what information should be protected, all those sorts of things. They have been well laid out and they have matured over 60 years, so I think using that as a model and then using the specific parts that healthcare need to take on board, that is certainly manageable by next April to have written these principles.
Q57 Mr David Jones: Is that a precise analogy though, because clearly there are far fewer incidents—thank goodness—in the aviation industry than there are in healthcare?
Keith Conradi: But it is the principles of how the investigation is done. I do not think that changes whether it is one person or a themed study, where there may be 40 or 50 people who have had harm done. I think you can still use the same principles of how you investigate, what you protect and what you do with the information.
Q58 Mr David Jones: I can understand that, but isn’t it also a question of deciding which events you investigate?
Keith Conradi: Yes.
Q59 Mr David Jones: Won’t you need to develop principles for that?
Keith Conradi: I certainly think we need to develop the criteria for deciding what becomes a full HSIB investigation, yes.
Q60 Mr David Jones: That is very different from the case in the aviation industry.
Keith Conradi: Yes, absolutely, I agree that there is a clear definition of what an accident is in aviation. It is not the same in healthcare and that will need some work on it, yes.
Q61 Mr David Jones: Have you given any thought to those principles yet, as to what sort of test you will apply?
Keith Conradi: I am still getting my head around exactly where HSIB will need to eventually come into investigations in its own right, but I think there are certain things, big theme studies where data shows that there is a big difference in one area and something has changed, something that may be going on within a particular trust that the trust feels uncomfortable with and they want to highlight. There are things like Morecambe Bay. Again, I know I keep coming back to it, but I think that is probably a classic type of investigation that HSIB would undertake.
Q62 Mr David Jones: All the points you have just made lead me to still wonder whether 30 is an accurate assessment of the likely number of cases that the HSIB will be involved in.
Keith Conradi: I do not know as yet. I think probably after a year or so we will have a better idea of whether the resource matches the level that we would like to investigate ourselves.
Q63 Mr David Jones: You do not want to be constrained by the resource, you presumably would want to pursue individual cases where you felt there was a proper need to do so?
Keith Conradi: Certainly I would want to do that. If it started to become a real issue, I would be going back and saying, “This is under-resourced and we need to look at putting more into it”.
Q64 Chair: It was certainly my expectation as we concluded our report last year that made this recommendation that this organisation would need to be very much larger than AAIB in the end because of the sheer volume of incidents that require to be investigated. or am I missing something? I think the scale of it rather put off the Department, the idea of having this body at all, and if it does grow like Topsy, it might lose its focus. Can you say a bit more about this?
Keith Conradi: I think the focus needs to be on the local investigation capability. That may take some work, because that is going to take some investment, but I think that is where you can grow. The individual investigations are going to have to take place at that level, but there is a lot of work. From what I understand, there is inconsistency, there aren’t the principles out there for people to follow, so I think HSIB needs to set that and then there is going to be investment to bring all those individual local ones up to a level at which they can investigate small events.
Q65 Chair: In our initial report recommending this idea, we imagined that local trusts and GP practices would need to have in their organisations people with new qualifications for effectively what is a new profession of clinical incident investigation and that HSIB would need to promote a system of accreditation and examinations and that these bodies would need to massively improve their data, in the same way as airlines and aviators keep data religiously about their activity, that that kind of data and record-keeping would need to be developed in a way that is not systematic in the health service at the moment. How will you do that with such a small organisation?
Keith Conradi: I think you set out the principles. The investigation principles that we set for HSIB should be appropriate for all investigations that are undertaken, because as I say, it does not matter how big the investigation is, the principles should be the same.
Q66 Chair: But your effort is to change the actual practice of clinical investigations outside your organisation that would take place in the normal course of events in each trust, for example. How will you do that with such a small organisation?
Keith Conradi: We set a standard, we set training and, if necessary, we set accreditation and then it is a fact of saying, “This trust has set up this investigation team. This is what it is going to have to meet” and then it is a fact of then being checked and audited to ensure that that is what happens. In a way, it is kind of a microcosm. We have in aviation a central world body that sets out standards and recommended practices and then all the 190-odd contracting states then set up an organisation that meets those standards and that is audited against. I do not see why it should be any different in this way. In fact, that is done with a relatively small amount of staff on a global scale.
Q67 Mr Turner: At what level are you expecting people to improve hugely the manner in which they keep records? Are you talking about at the top of an investigation or are you talking about daily nurses, because that will be necessary to focus what is happening?
Keith Conradi: I have not mentioned about record-keeping. That may be something that comes out of an investigation, which suggests that that is a problem. Data is important and I know there must be a massive amount of data that runs around in the healthcare industry. One of the ways of identifying themes will be to be able to analyse data in a timely fashion to be able to do that. I do not know how reliable that data is as yet, but one of the things that I envisage is as investigations take place and they start to uncover areas such as that, that is a key area where recommendations may be made. It is not just on a technical or human factors, it could be on the administration of what is going on. So I see that as an end result of an investigation, certainly.
Q68 Paul Flynn: Will the Healthcare Safety Investigation Branch be unique or are there other examples of ones working in other parts of the world?
Keith Conradi: Some of the multi-modal accident investigation bodies around the world do have a remit to go into healthcare investigation. Sweden is one, for instance, and I think Norway is looking at it as well. As far as I know, it is a very rare event that they go in and do that.
Q69 Paul Flynn: Do you see a danger in the blame culture, which has brought a lot of anxiety to people working in social services, for instance, who are always responsible for everything that goes wrong in their area of work; of having a defensive culture created in the health service, such as exists in America, where there is excessive medicine in order to avoid being sued afterwards and there tends to be an attitude of using every possible remedy that is available, often to the detriment of the patient, in order to defend themselves from investigation in future?
Keith Conradi: I do see this defensive culture. From everything I have heard, it is one of the big differences between aviation and healthcare. What I would like to think would happen is that having this no-blame investigation and demonstrating that it does work without blaming people, it will then become more normal within NHS investigations. But there is going to be a period where we are going to have to produce investigations before we are going to get the full trust. I imagine there will be an element of suspicion to start with.
Q70 Paul Flynn: We have all been upset by the examples of the scandals in the health service over the last 30 years or so, and it does not seem to matter which Government is in power or which attitude, but they still occur and there are new ones. How do you think you are going to change the attitude nationally in the health service so it is not excessively defensive, but it does avoid these tragedies?
Keith Conradi: It is going to be demonstration. I can talk to everybody and say, “This is no blame, this is how works in aviation” but I think people will be waiting for those first reports to come off the printing press and go, “Right, is this any different?” I am sure there will be cynics out there waiting, but I think that is where we will cut our teeth on those initial investigations and proving that there is benefit and learning that takes place.
Q71 Paul Flynn: The example you quoted of an investigation was the one at Vauxhall Cross when the helicopter crashed into the tower. I witnessed that accident and I was very clear what was happening: the helicopter was flying low, it was very noisy and of course there was fog, you could not see the top of the tower from I live in Vauxhall. Now, that seems to be a relatively straightforward way of saying the crane that was hit was not visible enough, but the helicopter was flying too low on his journey to Battersea. Those concepts seem relatively simple, rather than investigating the death of a patient where there are huge complexities involved in the reaction of the medicines, the surgery, the doctors, the nurses and so on. Aren’t you going from an area where accidents were rather simply explained to ones of almost infinite complexity?
Keith Conradi: I don’t necessarily think so. Some aviation accidents are incredibly complex, not just technically, but systemic problems working right the way back through the industry. We have had huge problems in the North Sea with helicopters with many different accidents, and in fact the regulator eventually undertook a full review of what was going on. So our investigation does not just stop at the technical problem, it will look back and ask why, why, why, and that can move right up into the whole culture of an organisation. So I do not think the differences are perhaps as great as maybe you might think.
Q72 Chair: What do you think the relationship will be between HSIB and the PSHO?
Keith Conradi: I think it will be separate, but there needs to be a conversation that takes place where, if I understand it correctly, PHSO will look at the complaints and will deal with the complaint, but will not deal with an investigation. I can see that that might be one of the inputs that comes into HSIB, people saying, “We have had this complaint. Is there something that you can add to this? Is it something that you might want to look at further?” I just think it is another piece of intelligence that will come into our operation for us to make a decision on whether we want to take it any further.
Q73 Chair: But does this mean you will be requested to do investigations by PHSO?
Keith Conradi: I do not think that will be the case. I just think that they may see maybe a whole bunch of complaints coming in a particular area and might suggest that this might be something that we want to look at. Then we can take that with all the other information that we have and make a collective decision within the branch.
Q74 Gerald Jones: Mr Conradi, can you describe what success would look like in two years’ time and specifically how you would measure that success along the way?
Keith Conradi: I think we will have produced several reports that will have contained safety action and safety recommendations. I think there will be published responses to those safety recommendations that show a clear change of practice or whatever is required within the industry. I think thereafter, when we go into investigations, we will be met by people who are willing to talk openly to us. I think that whistle-blowers and the like will become less and less of an issue as we move forward and that we will be greeted with an acceptance; in fact, people will be pleased to see us come into an investigation rather than with an air of suspicion. That to me is that cultural change that in fact, if you like, is more significant than anything. That is what I will be looking for within a couple of years.
Q75 Gerald Jones: Do you think two years is a realistic timescale for that type of change?
Keith Conradi: Possibly not. You mentioned two years. I would like to think we would be well on the way. It is a huge industry. There will always be people who will be wary. Even in aviation it is not perfect and we have been doing this for 100 years, so it is a long-term process, but I think we have to start and this is a fantastic opportunity to start now and move in that direction.
Chair: Are there any further questions? Thank you very much for coming before us today and we hope that we will be able to give an indication of our conclusions to this pre-appointment hearing very quickly. Thank you very much indeed.
Keith Conradi: Thank you very much.
Oral evidence: Chief Investigator, Healthcare Safety Investigation Branch, HC 96 3