Public Administration and Constitutional Affairs Committee
Oral evidence: Follow-up to the PHSO report: Learning from Mistakes, HC 743
Tuesday 8 November 2016
Ordered by the House of Commons to be published on 8 November 2016.
Members present: Mr Bernard Jenkin (Chair); Ronnie Cowan; Paul Flynn; Marcus Fysh; Mrs Cheryl Gillan; Kelvin Hopkins; Dr Dan Poulter; Mr Andrew Turner.
Dame Julie Mellor was in attendance.
Questions 1-70
Witnesses
I: Scott Morrish, father of the late Sam Morrish and Member of the Healthcare Safety Investigation Branch Expert Advisory Group, and Dr Steve Shorrock, Human Factors Specialist.
II: Professor Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission, Helen Buckingham, Executive Director of Corporate Affairs, NHS Improvement, and Keith Conradi, Chief Investigator, Healthcare Safety Investigation Branch.
Witnesses: Scott Morrish and Dr Steve Shorrock.
Chair: My apologies that we are running over time, but we need to try to complete both sessions within an hour. We will do our best. Can I ask our first two witnesses on this session on the PHSO’s report “Learning from Mistakes” to identify themselves for the record, please?
Dr Shorrock: My name is Steven Shorrock. I am a chartered psychologist and chartered ergonomist and human factor specialist, and I work for Eurocontrol, which is a European organisation for safety of air navigation.
Scott Morrish: My name is Scott Morrish. I am Sam’s dad, and that is the reason I am here.
Q1 Chair: Thank you both for being here. In this relatively short session we want to give you the opportunity to say what you need to say, rather than us asking a whole lot of questions as though we were holding you to account. Can I kick off with an initial question to get you going? Mr Morrish, you asked PHSO to undertake a second investigation into your case because you felt its first report in 2014 did not deal sufficiently with the systemic issues underlying the mistakes that you felt led to Sam’s death. How satisfied are you now that the report has got to the bottom of these issues?
Scott Morrish: It is a huge step forward. I think it is probably as much as we could hope for from a complaints system. It gives you a glimpse of what could be delivered through learning investigations, and in that context I think my role now is to try to capture what may be missing from it and to map it across the rest of the system so that others can do more with it.
Q2 Chair: What do you think were the key reasons that organisations investigating Sam’s death failed to do this effectively?
Scott Morrish: I think the main reason that they failed would be put down to a combination of basic human responses in tragic circumstances, which would be affected by fear of having failed in some way and being responsible. Then it was compounded by very poor governance and, in the end, a system that really has no checks and balances unless they come from the family.
Q3 Chair: Say a bit more about the poor governance and the lack of checks and balances.
Scott Morrish: In our case, for example, one of the key people involved, the paediatric consultant, was not only responsible for the team that was looking after Sam in the hospital, but was also pretty much given carte blanche to deal with the investigations that followed. It was not fair to him, and it was never going to lead to objectivity.
Q4 Ronnie Cowan: Mr Morrish, in terms of the complaints and investigation process, what were the discrepancies between what you got and what you expected from the PHSO?
Scott Morrish: In the first or second investigation?
Ronnie Cowan: Between the two.
Scott Morrish: Can you just ask that again?
Ronnie Cowan: I am looking at the complaints and investigation process. What did the first report deliver or not deliver that you feel you got from the second report?
Scott Morrish: The first report went into some detail around what happened to Sam. The second report went into details about how the NHS failed to investigate, and that was an integral part of what I needed—what I basically think the system needs to know in order to be able to avoid these things happening again. Does that answer your question?
Q5 Ronnie Cowan: To an extent. I am looking for detail around this. When you read the first report your heart must have sank and thought, “We have not answered any questions here.” What did you see in the second report that made you think, “Finally, we are getting there. Finally, we are getting answers”?
Scott Morrish: In the second report we felt like a light was being shone on to the reasons that the system was failing. I do not think it covers all of the elements that need to be covered, but I think it shines a light strongly enough to allow more information to emerge now. I am interested in the tone that is set at a national level and the impact that has at a local level. I think people on the ground are in fear, to some extent, of the regulation and regulators, and they operate in a culture that is dominated probably by shame more than anything else. That is counterproductive. I would like to see that changed nationally in order to support better conduct locally.
Q6 Ronnie Cowan: The PHSO’s Learning from Mistakes report highlights the extent to which information received by patients throughout their investigation process was piecemeal and incomplete. What should meaningful and effective communications and involvement of families and carers in investigations look like?
Scott Morrish: It should be inclusive. Everybody involved in the sorts of circumstances we found ourselves in should be included in the process of unearthing what happened. They should be gathering perspective from everybody, because that is where resilience comes from in investigation. It is only once you have captured all of those perspectives that you can know with any certainty whether you have found out what happened. In our circumstances, basically the poor governance allowed control to rest in a very small number of hands, and for a number of reasons, including fear and poor process, they basically did not want to be confronted with those other perspectives. It challenged identity and their understanding of themselves, and it was deeply uncomfortable.
Q7 Ronnie Cowan: Fear of what?
Scott Morrish: Fear of an altered impression of their own capability, their standing among their peers and their ability to conduct their jobs and therefore provide for their families. Fear of the media. Fear of the regulators is a big one too. Fear of patients—we ended up becoming quite an intimidating presence.
Dr Shorrock: Yes. I think patients as well as staff should be seen as experts in their own field, in their own experience, so in a sense they are all field experts. If you do not understand the patient’s story, you do not really understand the story at all. Therefore, as Scott just said, they need to be involved as an expert in their area, in their experience, from the very beginning, as well as the staff. That means doing very careful interviews by very skilled, competent and independent people.
Q8 Kelvin Hopkins: A question to both of you, really: what system and processes need to be in place in order to embed an effective safety culture in an organisation such as the NHS?
Dr Shorrock: This is a very big question. First of all, we need to think about the way that we think about safety. There are generally two views of safety, and one of them dominates. The first view, which we call the first story, is that a system is fundamentally safe were it not for individual practitioners who make it unsafe. When we adopt that mindset, we adopt simplistic solutions that are either ineffective or counterproductive, quite often involving blaming individuals. The second story is that the system is basically not safe but individual practitioners routinely make it safe by adapting and joining up the gaps that exist in the system. The second story of patient safety is that we have a fundamentally unsafe system where there are systemic vulnerabilities and there always will be; practitioners routinely make it safe but occasionally they are not able to do that.
When you start to look at those vulnerabilities, such as the demand and pressure, variable resources, competency levels, lack of time, pressure from performance targets and so on, and you look at that second story, you approach that patient’s safety in a completely different way, which is harder but effective. That requires consistent leadership from the top. What that means is consistency between what leaders throughout the system say and what they actually do. It is very difficult to build a safe culture; it is very easy to destroy one by inconsistent leadership behaviour.
There is a key lesson there about how we think about systems, not as being fundamentally safe but as being made safe by the everyday actions of practitioners. The second part is that leaders need to have consistency between what they say, what they do, and what they record for prescribed work and policy.
Kelvin Hopkins: Thank you. Anything to add, Mr Morrish?
Scott Morrish: Only that I think it is patently obvious from almost everybody I have met that the will is there to get this right at the grassroots level. I believe a lot of the problems flow from the tone that is set from the top all the way through the regulatory framework, and sometimes from the advocacy groups as well. There is too much blame in the system. There is too much of a tendency to shame people for things they do. Really what we need to do is to be able to nurture that goodwill, harness it and allow it to be innovative in order to solve problems and reduce risk, and therefore ensure better outcomes for both patients and staff.
There are schizophrenic messages that come out sometimes from the top levels. On the one hand, you are talking about wanting a learning culture, which is a laudable thing to aim for. On the other hand, you are talking about very aggressive inspection regimes. There needs to be a balance that is struck more carefully, which is more nurturing, more careful and basically more compassionate to the staff so that they can deliver that in turn to patients.
Q9 Kelvin Hopkins: Thank you. What are the key changes that need to be made to make staff feel more secure in conducting these investigations as you have suggested?
Scott Morrish: They need to know that if they have made mistakes they can speak freely. They need psychological safety so that they can articulate everything that happened and allow learning to take place. What they also need to know is that when people have acted maliciously or there is gross negligence or recklessness, those things are dealt with sensibly. It is striking a balance between those two things. I think at the moment really all we have is a system that is pretty heavy on accountability and regulation, very heavy-handed regulation, but is very haphazard as to whether any learning comes through at all. It is almost an accident if learning takes place.
Q10 Kelvin Hopkins: What needs to happen in addition to the introduction of safe-space investigations?
Scott Morrish: Safe-space investigations need to be understood first, and the place for those to happen is in HSIB, the Healthcare Safety Investigation Branch. They can only be conducted in a particular context, and the context is investigations that are there to learn. I am not clear that it could be introduced at this moment in time at any other level. I think there needs to be some quick thinking around what safe space means, the context it can work in, and also understanding the fact that if you drop it into the wrong context you are probably going to hole it below the waterline.
Dr Shorrock: I think safe space, if it is implemented properly and correctly at the right level, is one part of a wider solution. Another part is a just culture taskforce, where we increase understanding among all stakeholders—and that probably includes the judiciary—about what just culture is. Investigations have to take place within a just culture context, and it needs to be clear that the aim of an investigation is learning, not the attribution of responsibility or blame. The only aim of a safety investigation is to learn and prevent reoccurrence. You may not prevent the exact same accident, because that is very unlikely to happen, but you may and you should address the systemic vulnerabilities that bring about these mistakes. Mistakes are just symptoms of a deeper problem within the system. We should not get too hung up with mistakes; they are merely symptoms of something that is going on underneath.
Q11 Marcus Fysh: As a follow-up, what are the lessons that you think can be drawn from the air safety world, other than what you have been saying already? Are there any crossovers that we should be looking to implement?
Dr Shorrock: On the air traffic side, we do have confidentiality in investigations from the beginning. Investigators, when they are at their best, try to get multiple perspectives from different people who are involved. Those multiple perspectives, even if they appear to conflict, are not a sign of weakness, they are a sign of strength because we see situations from different angles and we see different things. That is quite important.
Another very important thing is that, at their best, investigations do not just investigate the accident. They should be investigating the normal everyday work. We tend to assume that accidents and normal everyday work are two completely different things, but they are the same thing. Usually the conditions or the seeds for any accident were there and have been there for a long time. You can find those without the need for accident if you look. In a sense, the best place to start with an investigation, once you have the basic facts, is to look at everyday work and find out what those systemic vulnerabilities are.
That needs to happen within a just culture environment. The air navigation service providers that I work with will all have a just culture policy, for instance. It is signed by the chief executive and is understood throughout the organisation, so that people know where the line is between everyday mistakes and so on, which are a symptom of the systemic vulnerabilities, and gross negligence, which is something else. There has to be an understanding that people do not go to work to have accidents. They go to work to do a good job, and accidents happen to those people as well as to the other victims of those accidents as a result of the systemic vulnerabilities.
Q12 Chair: Thank you very much. The Department of Health has issued a consultation on how the safe spaces should be organised. Mr Morrish, you have already touched on your concern about that consultation. Would you like to say a bit more about that?
Scott Morrish: I think it is such an important issue, and it has so much potential. The safe space is part of something else. It is not an end in itself. The safe space is supposed to be part of a safety investigation that needs to be conducted in a specific context. The consultation worries me because it appears to reveal perhaps a lack of understanding on the part of whoever wrote it about the specific nature of safe space and the specific context in which it is needed to operate. They seem to be scratching around searching for a way of making it happen at a local level, and I do not think the culture is anywhere near ready for anything like that at the moment.
I would like to see them concentrate on making sure safe space is deliverable within HSIB. At the moment, as far as I understand it, the legislation that is needed to make that possible does not exist. HSIB is being asked to go out and conduct investigations fairly soon, while it does not as yet have the powers it needs to do that in the way that we are asking it to. It feels to me like a bit of a jump in the dark.
Q13 Chair: How should a chief executive of a hospital, for example, or a clinical director of an operating unit, conduct an incident investigation if they do not have recourse to the safe space? How are they going to avoid the blame culture?
Scott Morrish: They need to separate safety investigations that are focused on learning from accountability and line management and deal with those things separately. They have separate purposes, they are conducted in different ways, and they need to all be part of a just culture within any organisation.
Q14 Chair: But how will people talking to one kind of investigation, an accountability investigation if you like, know that if they are giving information to a learning investigation that information is not going to be passed from one to the other?
Scott Morrish: I suppose the assumption in my mind is that in most instances accountability will be something that comes in rarely in terms of any form of punishment. There is a different form of accountability that is making sure that we learn from mistakes and stop them happening again. That needs to be dealt with separately. More importantly, it is just being able to answer all the questions and gather in all those perspectives. You need to change the culture so that it is not riddled with fear and shame and it allows people to speak in the spirit in which they generally came in to do their jobs, which is to help people and to be kind.
Q15 Chair: How much do you recognise that there is something of a dilemma here? If we want to realise the principle of incident investigation being conducted via the safe space in order to give people confidence and that is not available locally, you are going to have a different culture locally.
Scott Morrish: My view is that that culture is set by the messages that come out of the Department of Health and the regulators. That is the GMC, the NMC, obviously watchdogs, people like the PHSO, but also the HCPC. It is holding the management to account for delivering a culture in which care can be delivered safely.
Q16 Chair: In the aviation sector, how is this safe space AAIB replicated at local level, at airline level, airport level or air traffic control level?
Dr Shorrock: It varies very much between different countries. In some countries the basic information that is collected about an incident or an accident at a national level by an investigatory body can be shared with, for instance, a prosecutor. This is around the world now. In countries such as Australia, I believe, no information can be shared. The two investigations have to be completely different from the beginning. In other countries all information is shared. There has to be clarity on what level of information is shared outside of that safety investigation. For instance, it may just be the basic facts but not the interviews on various other aspects of that investigation. You still do need some level of confidentiality from the beginning. If people do not feel safe to speak up, then simply they will retreat into their roles and will do what is natural, probably, for any of us to do.
Q17 Chair: But in an airline there is not a legal safe space?
Dr Shorrock: No.
Q18 Chair: And it works?
Dr Shorrock: My experience is with air traffic control providers, but there is a just culture policy and acceptance of some of the things that I have said already. There is an understanding that people do make mistakes but that those mistakes are a symptom of the deeper vulnerabilities in the system.
Q19 Chair: Even if the safe space is confined to AAIB, it can extend the no-blame culture throughout the entire industry?
Dr Shorrock: I would say so. Something like that has to be managed very carefully, probably starting with a national point.
Q20 Chair: How does it do that?
Scott Morrish: One of the key things about AAIB, as I understand it from a distance—but HSIB, in terms of what I am hoping happens, has this unique capacity to span the whole system. No local investigation can do that. HSIB can go everywhere. It has no barriers to its investigations and, as a result, that safe space enables it to basically shine a light on the system as a whole. I do not think it is practical to imagine that on a local level. You cannot do it from the ground up and span the whole system.
Dr Shorrock: The other thing that is important to understand here is that no individual investigation—and particularly in healthcare—can possibly have sufficient expertise to span the entire sector. That expertise has to live within a team of very competent investigators, led by a chief investigator, that reports independently to, for example, the chief executive as part of the team and is not going to be suppressed by other layers of management.
Q21 Chair: What is your reaction to that HSIB is going to be concentrating, as a sort of trail blazer, on maternity services?
Scott Morrish: I wanted complete independence for HSIB and I have never hidden that view. I want it to choose where to focus. I do not think it matters where its first investigation sits. All that matters is that it gets on with learning how to conduct system-wide, expert-led, learning-focused investigations, and then starts showing that learning in wherever its second, third and fourth investigations go. It does not really matter; it just needs to do the learning.
Q22 Ronnie Cowan: The PHSO 2016 report Learning from Mistakes has been seen as an improved report, but has the system that let Sam down so badly improved as a result of the report?
Scott Morrish: I would argue that very little has changed in the intervening period, and I would draw that conclusion based on the fact that we have been told for five years that the lessons have been learned. I would say the learning is only just beginning and, even more worrying, the change that needs to come, the action that needs to follow, has barely started. It takes a long time. It should not take this long. I do not know why people are so tolerant of it taking so long. There should be more impatience and a greater expectation.
Q23 Chair: This session feels very short to us, so you must add anything else that you feel you want to say. What would you like to say, if there is anything further you want to add?
Scott Morrish: One of the things that has troubled me the most is that I was pigeonholed as a problem from the very beginning. The way the system functioned, it had a closed mind from the minute Sam died, pretty much, to the idea that anything had gone wrong and that there could be any learning. We need to shift the whole focus away from the blame and the shame and the worries that go with that and the silence that it leads to. We need to shift that to one where the expectation is learning, no matter what happened. Whether it is good or bad we can learn and improve and have an expectation of supporting staff and supporting families, not pitting us against each other. Then hopefully these things will not keep happening or take five or six years.
Dr Shorrock: I think there is probably a tendency in healthcare safety to distance ourselves from various events by looking at differences and saying, “It is different here. We are in a different part of the sector. We are a different profession”. We probably need to start looking a lot more at similarities between the ways that things work in different parts of the system. Fundamentally, most adverse events in healthcare do have at their heart a certain level of pressure, which is one of the system vulnerabilities that I keep mentioning. Again, as I mentioned earlier, that pressure is there regardless of whether or not there are any accidents and that can be understood regardless of any accidents.
One thing that is really fundamental that we need to do, to go back to our first point, is to understand that the system as we imagine it and the system as it is found are two completely different systems. The system that we imagine is a very different one to the system that really exists, where resources are often inadequate, the constraints affect the work in a way that is counterproductive, and pressure makes everyone’s job, especially practitioners, much more difficult. We have to focus on the system as we find it, the work as it is actually done, and not the one that we imagine at the top. That means we need to involve an awful lot of people to understand how the system really works if we want to understand and improve it.
Q24 Kelvin Hopkins: In coming to conclusions in a case, if there are serious problems—understaffing, inexperienced staff, and unacceptable pressures—is that focused on as a key conclusion, not as an excuse but as a factor in what has gone wrong?
Dr Shorrock: It certainly is. All human work is driven by demand, which results in pressure when resources are inadequate or when constraints are inappropriate. All human work is characterised by basic goal conflicts between, for instance, the need on the one hand to be thorough in checking, diagnosing and executing procedures, and the need to be efficient. We always have to make this trade-off and this will be behind most adverse events. We must stop thinking that adverse events are events with big causes because they had a big outcome. In fact, they are just everyday work that clinicians have to cope with on a day-to-day basis.
Scott Morrish: The one other thing I would like to draw attention to is everybody—and I would say in the past this Committee too—has been very focused on quantities. You quantitatively evaluate everything but qualitative accountability seems to be nowhere on the radar very often. This is an example where quality is being looked at, and I am really grateful for that. You cannot regulate your way out of these problems. You have to nurture and harness the goodwill that is there at the ground level.
I recently sat in a meeting with a lot of members of staff from all across the country from all different parts of NHS talking about what it felt like to be at work. They were describing isolation, anxiety, feeling disenfranchised and disempowered. Often these are the people who are caring the most but end up not really knowing how to cope with the jobs that we are asking them to do. The flipside of that is you could sit with a group full of patients and people who have gone through experiences like I have, and we would use the exact same language and have the exact same feeling of being disenfranchised and disempowered. All you need to know about that is it is telling you the system is wrong. There are solutions, it does not need to take long, but we need to start addressing those things more than thinking about things like funding.
Q25 Kelvin Hopkins: Do you think we might learn something by looking at other jurisdictions and other countries where they have health services and things perhaps are better?
Scott Morrish: I would always welcome that, but I would say, first and foremost, let’s look at ourselves honestly. I do not think we have done that enough.
Q26 Chair: How do you think we should measure progress as HSIB is developed and starts its work? How should we identify what constitutes progress?
Dr Shorrock: I and my colleagues go into organisations every three or so years to have workshops, typically lasting a week, where we will speak with everyone from the chief executive and the board through to the various specialists and the frontline, sharp-end operators and practitioners. For me, progress is what I hear from them, it is their stories, and in this case it will include patient stories as well. It is that qualitative evidence that Scott was just talking about. You are not necessarily going to measure progress in terms of numbers of accidents, for instance. You have to spend some time talking to people to understand how things have changed over time.
Q27 Chair: Why do you think the just culture taskforce recommended by the EAG emerged as a proposal from the Expert Advisory Group?
Scott Morrish: Initially I was quite confused by it, because I thought, “Do we really need to be talking still? Should we not be getting on with it?” But over the last few months I have realised that the lack of understanding about what just culture means and how you nurture it is so deep and at every level. I think the just culture taskforce could serve a really useful purpose in helping hold the leaders and the policy makers in a space where they start understanding this and really grasping what it means for people all the way through the system. At the moment, I do not think that understanding is there. Asking system leaders to nurture it seems like a tall order until they have figured out what it means. I was just going to add one more thing—
Chair: Sorry, can we have Dr Shorrock on the just culture taskforce?
Dr Shorrock: What we have learned in aviation is there has to be consensus on the need for a just and fair culture that is about learning as a whole. If you do not have that consensus from a range of stakeholders—which will include, for instance, prosecutors, judges, frontline practitioners, patient representatives, staff and practitioners—you will always have something in your system that is pushing against it. Therefore, an inclusive taskforce where people are trying to understand each other’s worlds is really the only way to go about it. We have certainly learned that that is the only way to get people understanding the need for a just culture, and also to understand each other’s worlds, that the world of the judiciary is very different to the world of practitioners, and both of those worlds do need to co-exist.
Scott Morrish: You asked the question a few minutes ago about how we would measure progress. Here is one example: NHS England were very keen, when the first PHSO report was published, to explain that lessons have been learned and to show what they were doing about it. Really it boiled down to they had created a leaflet that was a tool for parents to triage their children—how to spot sepsis and spot the sick child, effectively. But what followed when the pressure was off was a period of inertia and underwhelming evaluation that nobody respects and as a result it is going nowhere. It has not happened and we are now six years down the line.
I would say that a sign of progress would be getting a tool that can help parents know how to triage their children. It does not have to be this one, it does not have to have Sam’s face on it, but parents need that information and the clinicians need that information. My measure of progress is that they have not done it.
Q28 Chair: They have launched an initiative, but it has not changed anything?
Scott Morrish: They thought that it was okay to do this and then did not do a proper evaluation, so they cannot get the blessing of people like the UK Sepsis Trust or the royal colleges or Public Health England and, therefore, it is just stuck. They are now talking about possibly another two years in which it might be evaluated, but in the meantime eight years have passed. I think that is quite poor.
Chair: Very helpful. You are both extremely articulate and particularly, Scott, we have huge admiration for all the work you have done. It is a tremendous service to future generations, and it is, I hope, having a real effect. We will do our best to make sure that your work is fruitful.
Scott Morrish: Thank you very much.
Chair: Thank you very much for coming before us.
Examination of witnesses
Witnesses: Professor Sir Mike Richards, Helen Buckingham, and Keith Conradi.
Chair: Welcome to our three further witnesses for this session on the PHSO’s report Learning from Mistakes. Could you each identify yourself for the record, please?
Professor Sir Mike Richards: I am Professor Sir Mike Richards. I am the Chief Inspector of Hospitals at the Care Quality Commission.
Helen Buckingham: I am Helen Buckingham, and I am the Executive Director of Corporate Affairs at NHS Improvement.
Keith Conradi: I am Keith Conradi. I am the Chief Investigator of the Healthcare Safety Investigation Branch.
Q29 Chair: It is very good to see Mr Conradi in front of our Committee again since your pre-appointment hearing. Could you tell us how you think you are getting on?
Keith Conradi: We are definitely going to deliver an operational service by April next year, as is our requirement. We are busy recruiting at the moment. We should have an investigation team in place early next year, and there is a host of other practical arrangements that we are making to get ourselves ready to go.
Q30 Chair: When you appeared before us, you said that this was an opportunity of a lifetime. Do you still feel that?
Keith Conradi: Absolutely, yes. The more I delve into it the more excited I am by the challenge that is out there and the fact that I really think that the investigation team that we are setting up and the culture we are going to bring in can make a real difference.
Q31 Marcus Fysh: The PHSO’s investigation into the case of Sam Morrish highlights the specific need to improve the quality of local NHS investigations. This was also a key reason for setting up HSIB. How has PHSO’s Learning from Mistakes report contributed to your plans to improve local NHS complaint handling and clinical investigations?
Keith Conradi: At the moment we are focused on providing an investigation model that will work on a national level. Looking at the recommendations that came out of that report, they all are going to be incorporated into the way that we will do business. The further aspiration from HSIB is that we look at the quality of the local investigations, but that is very much after we have established ourselves as the national investigation body.
Q32 Marcus Fysh: In their response to our 2016 report on NHS complaints investigations the Government said they were considering how the principle of safe space can extend to HSIB and local investigations. What scope do you think there is for such an expansion, and does it hold any risks?
Keith Conradi: From my perspective, the principle of safe space should be limited initially to the HSIB investigations. I would be very concerned if people used that principle without really understanding it and being fully trained in it. There is a danger that information could be used inappropriately, and that would then undermine it for everybody, particularly ourselves. We will go to great lengths to ensure that we use it very sensitively and appropriately to our investigations.
Q33 Marcus Fysh: In your pre-appointment hearing you envisaged that the learning-focused investigations should be a totally different area from the existing investigations. What other concerns might you have that an expansion of the safe-space principles to all investigations might make it harder to hold people to account for individual wrongdoing where it has occurred?
Keith Conradi: We are in the process of setting up protocols on how we work with the other authorities who have a right to investigate. We will be the ones who are doing it purely from a safety perspective, but I think there has to be an understanding of what information can be passed to other people who are potentially carrying out parallel investigations and what cannot, and what procedure they may have to go through to do that. I think we need to set up and establish those protocols, as the national body, and just look to see how they work. The local investigations are very much down the line. I think we need to look at our experience and then see what the local investigations can learn from the way we are doing things and the feedback that we get.
Q34 Marcus Fysh: Are there any ways that you have in mind about how those national investigations might, from a structural point of view, in the future look at ways of informing what does happen locally?
Keith Conradi: On a local scale?
Marcus Fysh: Yes.
Keith Conradi: I would like to think that we can probably set standards; a type of methodology that we would use. We are setting up a professional investigation body, and a lot of the people that I am going to be employing will be professional investigators. They will include human factors experts as well as clinicians. I think we need to look at that model. I don’t think all of that will be translatable on to the smaller scale but perhaps the overall structure of the local investigations needs to be considered before we can see exactly what we can move across.
Q35 Chair: Professor Richards, Helen Buckingham, anything you want to add on the questions that have already been asked?
Professor Sir Mike Richards: I think only to say that the three organisations are absolutely committed to working together. We have our separate roles, but they are complementary. Clearly, as HSIB comes into being we will work very closely with Keith Conradi, but we will also respect the safe-space nature of his investigations. At CQC our role has been, first of all, to carry out inspections of trusts, where we do look at incident reporting, learning from incidents, and increasingly we are looking at the quality of investigations that trusts have done.
I am sure you are aware that earlier this year we published a report on a sort of deep dive into 74 serious investigation reports that have been done across 24 different trusts. In essence, we found that they were not being done well and there were all sorts of problems. I can go into details, but there were problems at almost every step in the line. We absolutely recognise this is an area for improvement, and we will work with our colleagues to drive this forward.
Q36 Chair: Does it become the role of NHS Improvement to promote best investigatory practice or is that the job of HSIB? I know HSIB is part of your organisation at the moment, but let’s assume they are separate. Whose responsibility is it?
Professor Sir Mike Richards: I think the whole system has different responsibilities, and we need to work together on being absolutely clear about what our responsibilities are and who is leading which bit forward. One of the proposals that I have made—I have a second role as co-chairman of the National Quality Board—is that the whole topic of investigations should come to the National Quality Board, where we have representatives from NHS England, NHS Improvement, NICE, Health Education England, Public Health England and CQC. We have all of those around the table and we will then say, “Who needs to do what?” As the case of Sam Morrish showed, the acute trust, the CCG and NHS Direct were not doing what they should have done. To get this right, we all need to have a role in improving things.
Helen Buckingham: I support what Mike is saying. I think it is very easy to say that we have a collective responsibility for this, but once you start talking about responsibility you can then lose individual roles. I think across our three organisations essentially we see the role of HSIB as being setting a standard, setting the bar, the role of the CQC broadly as holding the mirror up to the system and saying, “Are we meeting that bar?”, and then for NHS Improvement and NHS England, working with commissioners to work with local organisations—either individually or collectively—to help them to improve where they need to.
The other thing I would like to add—you may have some further questions on this anyway—is that I was particularly struck and not surprised by some of the comments made by the earlier witnesses about the need to work on the development of a just culture. That is certainly something that we have identified very early on in our life as NHS Improvement. We have some work going on now, a toolkit that we have established—by working with some trusts that demonstrably do have good cultures and have been identified as outstanding by the CQC—to help trusts diagnose where they are now and understand what they need to do to improve their culture across a number of facets. One of those is very much about creating a learning environment. Another one is very much about the compassionate leadership that is needed to help people tease out how they manage to run investigations that enable learning while not shying away from accountability where that is important.
Q37 Ronnie Cowan: I may have missed your earlier answer, but it is worth repeating: how has the PHSO’s Learning from Mistakes report contributed to your plans to improve NHS complaint handling? I missed that.
Helen Buckingham: In terms of complaint handling, as distinct from investigations—obviously it is an aspect of the work—it has certainly been a very valuable report for us in looking at our thinking in any case. We are taking information from other sources, including the CQC. We are, as NHS Improvement, developing a three-tiered approach to working with providers, looking at a universal offer, which is through our complaints forum that we work jointly with the CQC, around—
Q38 Ronnie Cowan: How has this report been implemented then? How has it improved the situation?
Helen Buckingham: The recommendations from the report will go into that universal work that we do with all providers. Then also through our regional teams we identify providers that need perhaps more targeted input. One of the things that we will be looking at is: do we have evidence from other providers where we are seeing some similar issues to the issues that were identified in this report? It is certainly one of the pieces of information that would play into our assessment of where providers need more help.
Q39 Ronnie Cowan: One of the recommendations from the report identified a failure of multiple bodies to work with each other and produce a single investigation. How are we going to fix that?
Professor Sir Mike Richards: I think that is precisely why we need to take this to the National Quality Board. The PHSO report Learning from Mistakes is a wonderfully clear deep-dive into a single case. It is a tragic case and it is a terrible thing that it has taken as long as it has to get to the point of us acknowledging this was both an avoidable death and, at the same time, that the investigations were done badly by all the different parties. I think that single case can be very useful, but put that alongside what we, the CQC, reported on earlier this year, which maps on to it very closely, on 74 different serious investigations and the work that we are currently doing, which is to look specifically at how trusts investigate deaths. This arose partly out of the situation at Southern Health, which you will no doubt be familiar with.
I think we will need to take all of that together and say, “How can we learn?” For example, in the case of Sam Morrish, if I understand it rightly, it took several months to identify the organisations that needed to be involved in this. I suspect if you talk to Mr Morrish you will hear that that could have been found out within several hours, not in several months, identifying who needed to be part of this. That is formally at the moment a role for the clinical commissioning groups to take on. In that era it was the primary care trust. I think we need then to see how well that is functioning, and how we could support that and do that co-ordination role more effectively.
Q40 Ronnie Cowan: This all seems to be happening at a very high level. There are organisations and administrators and managers. At what point is somebody going to roll up their sleeves and get into hospital wards and A&E, and say, “Let’s make this better and don’t be afraid of making mistakes”?
Professor Sir Mike Richards: I could not agree with you more.
Ronnie Cowan: I am asking when.
Professor Sir Mike Richards: I think we are already taking action. The CQC has put increased emphasis on looking at how trusts do investigations and how they select which cases need to be investigated, how they undertake the investigation but, importantly, what they learn from it.
Ronnie Cowan: We are doing investigations on investigations.
Professor Sir Mike Richards: That has proved to be necessary in this case, and that is what should not be the case. One of the questions that I ask chief executives when I am inspecting hospitals is, “Can you tell me about something that has gone wrong and a change that you have made as a result of that?” To my mind, it is quite a powerful question to ask: what has been changed? There are cases where some of them say, “We conducted this investigation and as a result of this we have made the following changes so that it is much less likely to happen again.” I wish I could say that was true across the country.
Helen Buckingham: If I could come back to the tiered approach that we are taking with trusts, where we are working with our regional teams and identifying trusts that demonstrably need support in this space, and I am thinking particularly of complaints but investigations more widely as well. We are working directly with a small number of individual trusts and we are providing some more general support to a wider number. There are at least three trusts that our complaints team are working with directly to help them understand how they should improve their processes so that they do follow through on complaints more effectively. That is complaints, as distinct from wider investigation, but we would expect to extend some of the learning from that into the investigation space as well.
Keith Conradi: At the moment I see the HSIB setting the example. We are just concentrating on bringing that professional approach to investigation. We will see where that goes from nationally. If we have the structure right, we can raise the level and the standard, and also stop the variability. I understand there are pockets where it is very good and there are places where it is extremely poor. What we will try to do is make sure that there is a consistent standard that is set at local level.
Q41 Ronnie Cowan: Were things better years ago? Is there a perception that we have moved away from a working NHS to this shambles that we have?
Professor Sir Mike Richards: I do not think we have a shambles. Let us remember that many things about the NHS are getting better. If you look at mortality rates in hospitals, over the last decade they have consistently declined.
Q42 Ronnie Cowan: That was my question: is it the perception that it used to be better?
Professor Sir Mike Richards: Then let me explain. We have seen those improvements. We have seen improvements in the management of patients with stroke, cancer, trauma, with a whole range of different conditions. I think we can point to those. That does not mean that we have solved all the problems and I think there are still serious incidents that could be avoided in the future if we had a learning culture. That is exactly what we were hearing from the previous witnesses. What we collectively need to do is to push the system towards being more of a learning system rather than a blaming one.
Helen Buckingham: I do not think we are in a perfect place, but one of the things that we all promote very strongly is that good organisations report incidents as part of learning from them. One of the things that we are seeing is that, on balance, when you triangulate your views of them, better organisations do report more incidents. From our point of view, that feels a positive indicator of an open culture. It is not all the way yet, but it can lead to the perception that there are more things going wrong than has been the case in the past. What I would say in general terms is that what we have done is shone a spotlight on those things that are going wrong so that we can start addressing them; it does not mean that there are actually more things going wrong.
Professor Sir Mike Richards: Can I add to that? In the national reporting and learning system—which is where incidents are reported centrally—four years ago there were about 900,000 incidents across the country being reported a year, including ones with no harm at all, and that has increased to 1.3 million. The increase is in those with no harm or very low harm, not those with moderate harm or severe harm or death. We are tracking that and we are encouraging the reporting of no-harm incidents, because those are potential learning opportunities. Clearly we want to see a reduction in severe harms and death.
Q43 Ronnie Cowan: Who is responsible for co-ordinating investigations at the local level?
Professor Sir Mike Richards: If it is a single trust involved, that single trust is responsible. If it is an acute hospital and the person dies within that acute hospital, they should conduct the investigation. Supposing it is a death that has occurred, the first thing they should do is look at is reviewing what happened in that death. Are there any concerns about the death? From then onwards they should then say, “Yes, we do need to do an investigation,” but critical to this, they need to involve the relatives and carers if somebody has died. That is something that I think does not happen well at the moment.
Q44 Ronnie Cowan: Finally from me, how are investigative practices evolving to ensure that families are being appropriately informed and involved during investigations?
Professor Sir Mike Richards: We identified in our series of 74 serious incidents that this was not happening. We have published that in order that it is known. It clearly did not happen in the case of Sam Morrish, and I am sure it is true in other cases as well. What we need to do is make very clear that there is an expectation that there will be involvement of the families and carers. When we are reviewing trusts and inspecting them, we will look to see if that is happening.
Q45 Kelvin Hopkins: You have touched on my question already, but I want to give you an opportunity to expand a little. On 3 March this year the Secretary of State for Health said that the NHS needs to become, in his words, “the world’s largest learning organisation”. How are you system leaders making sure that every opportunity is being taken, not just to investigate but to actively learn from the vast number of complaints pouring into the NHS on a daily basis?
Professor Sir Mike Richards: Looking at whether an organisation is a learning organisation is part of what we do through our inspection process. We always look at the reporting of incidents and the learning of incidents as part of our assessment of whether a trust is safe. We ask those same questions whether we are going into the accident and emergency department, the medical wards, the surgical wards, the critical care unit, the maternity unit, and so on. In all our inspections we look at the reporting of incidents. We talk to the staff, “Are you encouraged to report incidents? Are you getting any feedback? Is there any learning coming back from the organisation?” Then we look at a sample of incidents that are at the more serious end of the incidents and look at how they are being investigated and whether there was any learning from them. We are making this a very central part of our inspection regime.
Helen Buckingham: In addition to the work with individual organisations that the CQC highlight, increasingly we are starting to take a thematic approach, so identifying issues that we believe to be common across the NHS. Mike has already referred to the report that he is pulling together about deaths. The patient safety team that was originally at NHS England—I think they gave evidence to you last year—is now part of NHS Improvement and is focusing on two areas, pressure ulcers and falls, which are both significant areas where avoidable harm can be reduced.
Q46 Kelvin Hopkins: The 2015 NHS staff survey reveals that only less than half of all respondents, 43%, felt that staff involved in near misses, errors and incidents were treated fairly. What are you doing to address this evidence of a blame culture within the NHS?
Professor Sir Mike Richards: Shall I take that one again to begin with? The NHS staff survey is an incredibly important survey, and the fact that every single trust participates in it is really important. One of the things we have been actively encouraging is that they should take a census of all of their staff, rather than just a sample of staff, because I think that would prove to be much more powerful. That is happening; the number of trusts that are doing a full census is going up. We look at that staff survey in all of our inspections, and it is a very good way of measuring the culture within a trust and the culture of openness. The question that you mention is one of about four or five questions that really are around the same topic. We do look to see whether we think this is a learning organisation. Alongside that we—
Q47 Chair: I am going to cut you off as you are giving a rather long answer. The question is: what are you doing to address this evidence of a blame culture?
Professor Sir Mike Richards: We are assessing whether an individual organisation has a learning culture or not as part of our assessment of whether it is well led.
Q48 Chair: How do you do that?
Professor Sir Mike Richards: Partly by looking at the staff survey, partly by holding focus groups with staff. We hear from the staff themselves whether they are encouraged to be open and have a learning culture.
Q49 Chair: Where you find evidence of a blame culture, what do you expect the leadership to do?
Professor Sir Mike Richards: To change. We make it very clear that that is why we are rating them down in terms of whether they are well led. That is very clear.
Q50 Chair: But the title of your organisation is NHS Improvement.
Helen Buckingham: That is me.
Chair: I beg your pardon, apologies.
Helen Buckingham: That is okay.
Chair: So what is NHS Improvement doing?
Helen Buckingham: I touched earlier on the culture toolkit that we developed and published last year. That was developed working with individual providers. It is available for every provider to access. Where we have an organisation that is identified by the CQC as being in particular need of improvements in its culture, we will work actively with the provider using that toolkit. We will shortly, together with all the other significant arms-length bodies, be launching a response to the reviews held by Lord Rose and by Ed Smith last year into leadership and improvement in the NHS. We have a framework that we have been working on collectively that is very much grounded in the work of Michael West from the King’s Fund who is very significant in the field of compassionate leadership. He is very clear about leaders needing to get under the skin of issues in organisations, to listen to understand what is happening and then to take effective action.
It is not about compassionate leadership being all soft and fluffy. It is about doing the right thing to support staff and to ensure that we are creating a culture that does deliver the right experiences for patients and, in the context of what we are talking about today, families. Again, that would be a very practical framework that will launch in the next couple of weeks.
Q51 Kelvin Hopkins: Following on from that, rather than when you discover a blame culture dealing with that case, is there not an argument for giving general advice, particularly to senior hospital managers across the country, that the blame culture is not what you are looking for? What you want to do is to learn from these investigations to make sure that accidents do not happen in the future.
Professor Sir Mike Richards: I can assure you that in all the dealings we have with senior management of hospital trusts we do emphasise that. We do that through overview reports that we are writing where we emphasise that part of being well led is having an open and learning culture and I do it in meetings across the country day by day.
Q52 Kelvin Hopkins: A question for Mr Conradi now: how do you plan to work with NHS Improvement and the CQC to effect a cultural shift towards learning in the NHS?
Keith Conradi: We are very much going to be independent in our thought and our action. As we go through an investigation and we uncover facts or areas in which we think improvement could be made, we will invite the appropriate body—whether it is CQC, NHSI or anybody else—and we will lay out the facts. There will be an expectation from us that they may wish to take some action as a result of what we have found as opposed to just waiting until the end of our reports. It is a matter of sharing with them the information that is appropriate and then making safety recommendations, if it needs to be that way, but my preference would be that they are encouraged to take safety action based on what we have found.
Q53 Chair: What are the key enablers of the learning culture?
Professor Sir Mike Richards: Leadership, leadership, leadership would be my answer to that. It is the people at the top setting the direction, making it very clear that this is an expectation and that they model it in how they work themselves. We see it in our outstanding trusts without fail and in a whole lot of other trusts too.
Keith Conradi: We have a role to play by demonstration, by coming in and taking the safety investigation—not apportioning any blame or liability—showing the learning that takes place at the ends of our reports and then ensuring that that is as widely read as possible.
Q54 Chair: When you are conducting an investigation, an inspection, from CQC’s perspective how do you capture the openness or not of an organisation?
Professor Sir Mike Richards: Effectively by talking to staff. They will tell us. It maps on to the staff survey but it is talking to those groups of staff. They will very rapidly tell us.
Q55 Chair: I come back to this question: what do you expect leadership to do if you find an organisation that is not prone to openness?
Professor Sir Mike Richards: We make it clear and that is why we have a rating for well led, which is part of our inspection approach.
Chair: But what you expect them to do? When they sit down at their next board meeting and you have rated them down on openness, what do you expect them to do, what techniques and procedures?
Professor Sir Mike Richards: For those who are really struggling, clearly they may come out as inadequate for leadership and we recommend to NHS Improvement that they go into special measures and then NHS Improvement takes that on and works very closely—
Q56 Chair: What would NHS Improvement recommend that they actually do?
Helen Buckingham: Some things can be done very quickly. A lot of the work with organisations on culture is a slow-burn. The first thing is the importance of the trust recognising that it has an issue.
Q57 Chair: We will take that as read, but when they come into their next board meeting, what is the kind of plan that you expect them to implement to improve openness?
Helen Buckingham: I would expect to see better systems than they would previously have had for engaging with staff.
Chair: But it is not a system problem; it is a cultural problem, an attitude problem, a behaviour problem.
Helen Buckingham: Indeed. When I talk about better systems than they might previously have had for engaging with staff, it is making sure that they do have processes in place that staff can use to raise concerns, inquiries, suggestions. It would be a range of processes because people will need to be able to interact in different ways. There may be some formal processes. They may be about formal board members walking the wards, or there may be some slightly less formal processes. Some trusts have introduced anonymous discussion boards where people can post questions, queries, concerns. Different ways in which the board and the executive team of the organisation can demonstrate to staff that they—
Chair: I hardly think that posting discussion boards for anonymous use is a great act of leadership.
Helen Buckingham: —recognise that they have had an issue in terms of staff being engaged and that they are looking for ways to hear what staff have to say. For some staff, particularly if you have had a long culture of poor engagement, it will be very difficult to come out in a named way.
Q58 Chair: Keith Conradi, what experience do you have from the aviation sector of finding a closed-down organisation that was resistant in the way that much of the health service seems to be?
Keith Conradi: I am struggling to find examples of completely closed down. I think having somebody like your previous witness, Dr Shorrock, coming in and talking to people and making them understand what can be achieved by having that type of culture is one of the answers. That has been embedded in aviation for quite a number of years. It is not perfect by any means but I think that is what you need. It is almost to see what are the benefits of this, what can you see, appealing to what really makes the chief execs tick, is where you get some cultural shift.
Q59 Chair: Without attaching any blame in this conversation, what do you hear in this conversation and see in other regulators and NHS institutions that right at the top is still looking to expand their imagination and their understanding of the challenge? Am I putting that diplomatically enough?
Keith Conradi: We haven’t engaged yet with any of the trusts and so it is difficult for me to say exactly what the landscape is out there.
Q60 Chair: I would just observe, as a Committee, we sometimes feel that words are being used without a full understanding of what the meaning of them really should mean. Does that make sense? It underlines that we have a very big hill to climb here but that is not to undervalue the huge efforts and the sincerity with which people are making efforts to understand the challenges and to make the changes. Does anybody want to comment on that? I have just made an assertion.
Professor Sir Mike Richards: We do have a big hill to climb. We all acknowledge that. It is a hill that can be climbed. There are trusts in the country that are doing a very much better job than others. We need to support the ones that are not and I am sure NHS Improvement will do that. We need to identify where it is being done well. That is our job.
Q61 Chair: It would seem to be underlined by Mr Morrish’s card with Sam’s name on the front. Here is an initiative that was started five years ago to try to change something and it didn’t change very much. How much is that an almost insurmountable challenge?
Professor Sir Mike Richards: I am a born optimist. I do not think these things are insurmountable. Like Mr Morrish, I do not think this needs to take decades. Maybe we have the right time now, with a combination of the PHSO report and our own reports and the organisations having that will at the top to make the change. The NHS is ready for it but they need support.
Q62 Chair: How does NHS Improvement change the behaviour and attitude of an organisation with over a million people working in it?
Helen Buckingham: The fact that we exist is a start, because we were formed from two bodies, plus the teams from NHS England, that did not have this remit and focus before and did not have the consistency. Now that we do exist, we are working very closely with the CQC and NHS England and the other appropriate bodies so that we have a consistency of approach, because that was definitely something that was missing previously. We not only exist but we exist within a very explicit remit about improvement support, so although we have regulatory powers, the trick is in the name. We are here to enable organisations to do a better job for patients and their families and to do it in a way that is supportive and holds people to account when that is appropriate but very largely supports people to do what they need to do.
An offer to the Committee that if it would help to provide evidence in writing on the cultural toolkits and the leadership framework that I mentioned, we would be happy to do that.
Q63 Chair: By all means, please furnish us with that. Finally to HSIB: what are the major advantages that you are looking forward to when you are independent of NHSI—without casting any aspersions on NHSI—and you have the safe-space principle enshrined in legislation?
Keith Conradi: The fact that when we make a decision to go to investigate something people have confidence that it has come from us, from our system, as opposed to anybody else suggesting it to us or forcing it on us. People can suggest it but I want everybody out there to know that we have made the decision that we will investigate this for our own reasons.
Chair: And the safe space?
Keith Conradi: Safe space will demonstrate that it can work. There are quite a few things that need to be tweaked to get it to something that will work but ultimately I think it is going to need legislation.
Q64 Chair: Did you author or help to author the consultation document on safe space?
Keith Conradi: No.
Q65 Chair: Were you consulted about it?
Keith Conradi: I have been consulted about it and I have—but my colleagues—
Q66 Chair: How happy are you with it?
Keith Conradi: There are quite a few areas that need to be changed.
Q67 Chair: Could you just say which those areas are or do you want to do this offline? I do not mind at this stage.
Keith Conradi: The primary one is the one I mentioned earlier that I think it should only initially exist to HSIB. There are areas over the use of the name, the discretion, legislation. There are a number of other areas that I think we can talk about but the underlying principle, though, is sound.
Q68 Chair: In view of the importance you attach to investigating what you think should be investigated, what do you think of the proposal that HSIB should concentrate on maternity services to start with?
Keith Conradi: We need to develop our own investigation criteria, which we are currently doing, and we should investigate things that match those criteria.
Q69 Chair: Will you be making a formal submission to the consultation?
Keith Conradi: The safe-space consultation?
Chair: Yes.
Keith Conradi: Yes.
Q70 Chair: And that will be made public?
Keith Conradi: I do not quite know what happens with those submissions.
Chair: We would be very grateful if it was made public in the spirit of openness and transparency. I am looking at another member of your panel. Fascinating. Dame Julie, do you feel we have pressed on the issues raised by your report?
Dame Julie Mellor: Yes. Perhaps dealt less with the issue of competence to investigate but that will flow from the work of HSIB longer term.
Chair: Thank you very much for your report. We have appreciated the opportunity to continue the debate about this very important reform.