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On his last day in office at the Healthcare Safety Investigation Branch (HSIB), outgoing Chief Investigator Keith Conradi wrote to the Secretary of State for Health and Social Care reflecting on his time at HSIB. He outlined concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB and the need to introduce a safety management system approach at all levels of healthcare.
Patient Safety Learning also shared our thoughts on the issues raised in this letter and we were keen to explore these issues, and Keith’s experience as HSIB’s first Chief Investigator, in greater depth. In this article, Patient Safety Learning provides an overview of the recent interview we had with Keith Conradi on this subject.
The full transcript is available here.
To begin the interview, we discussed the events leading up to Keith joining HSIB as its first Chief Investigator. He spoke about his background as a pilot and then joining the Air Accidents Investigation Branch, first as an investigator before later becoming its Chief Investigator. There has been much written about the safety lessons that healthcare can learn from the aviation industry. Keith reflected on how his investigation roles in aviation helped to develop his understanding of the importance of creating a safety culture and the role of investigations as part of this.
Subsequently he had been invited to a Select Committee inquiry considering the recurrence of avoidable harm in healthcare, where he noted that:
“I gave some evidence and it made me aware for the very first time what went on in healthcare. I was quite surprised by how little professional safety investigation went on, and certainly not on a national scale.”
One of the outcomes from this inquiry was to explore establishing a new independent, learning-focused safety investigation body in healthcare, the same model that exists in aviation. Keith, who was part of the Expert Advisory Group on this, reflected on the response from DHSC and NHS England at the time:
“I think in terms of the specifics, in terms of doing safety investigations, I think there was a lot to learn and there was a curiosity but a lack of understanding of what it really meant. I think there had been such a punitive culture of blame it was hard for some to understand how investigations that avoided blame or liability could be achieved. I had a number of conversations with Jeremy Hunt explaining how it would work. There was some reluctance on whether people would accept it - not the investigation itself but the end results and what would they do with the outputs of a safety investigation and how could this make a difference.”
Following this he applied for and was appointed as the Chief Investigator of the newly established HSIB in 2016.
Considering the significant career shift from aviation to healthcare, we asked Keith about what motivated him to make this move. He reflected on the challenge of this, saying:
“I looked at healthcare and thought wow it was almost like the aviation industry 30/40 years ago and I thought it was a huge opportunity to introduce into healthcare some of the culture and safety professionalism that work in the aviation system. And it’s not very often you get the chance to set up something from scratch, which could potentially make a big difference.”
He noted that there was a clear recognition at the time that safety investigations in healthcare weren’t being done well, that staff had little time or training to do this, and there was very little system thinking involved. However, before joining HSIB he wasn’t sure how professional safety investigations would fit within existing frameworks in healthcare. On this point, he said:
“It opened my eyes to the fact that there was no structure in place at any particular level that was part of a foundation for a safety system. My experience was that some trusts did it well and that other trusts didn’t. It seemed to be down to the people who worked there and their experience or enthusiasm for patient safety that made the difference, rather than a specific organisational structure.”
Discussing the quality of safety investigations in the NHS, Keith noted that this had definitely improved during his time at HSIB, with an increase in availability of training, including courses provided by HSIB, and the new Patient Safety Specialist roles. However, he also talked about the importance of having broader support for this, stating:
“You can have the best investigation going on at the basic level but how the learning is acted upon is crucial. It has to come from the top to give it the necessary gravitas. Recognition of safety by the Chief Executive will drive its priority throughout the organisation.”
One area that differs between healthcare and aviation is the level of engagement affected patients and families have as part of healthcare safety investigations. Keith noted that while there was still some involvement with families regarding airline investigations, such as asking how the pilot had spent their last 24 hours before they flew, this on a very different scale to healthcare.
Keith highlighted how HSIB had recognised the importance of patient and family involvement in investigations at an early stage, saying:
“Some of the best information comes from families who may have sat by the bedside of a patient for sometimes days and weeks on end. It’s extraordinary how much insight they can give us about the culture on that ward. It’s a core part of any investigation and I think our family engagement has been one of the big successes to the investigation programme within HSIB.”
In our Mind the implementation gap report earlier this year, a key issue we highlighted was the need to ensure that there was a system-wide approach to not only sharing the findings and recommendations of HSIB investigations, but also effective transparent performance monitoring to ensure that the accepted recommendations translate into action and improvement.
When asked about responses HSIB had first received to their safety recommendations, Keith said:
“We were pleasantly surprised that many recommendations were accepted and acted upon – without a system in place and without legislation. But the next bit – have you done it, what difference does that make, what further needs to be done– needs to be addressed.”
He spoke about there being some particularly good examples of sharing learning and improvements at a regional level from maternity investigations, but noted difficulties when it came to national bodies, stating:
“With bigger organisations, and NHS England received most of our safety recommendations, it was harder to get a quick response and action started. In some organisations there just wasn’t a system in place to clearly identify the process of receiving, signing off and acting on safety recommendations. I understand that HSIB safety recommendations are a relatively new concept and anticipate that organisations will improve their handling of them over time.”
In his letter to the Secretary of State, one particular issue he highlighted concerned delayed NHS England participating in HSIB Covid related investigations and how this reduced the safety impact of their output. We asked him about the sense of frustration that came across in how NHS England engaged with these investigations. Commenting on this, he said:
“Our philosophy as we went through an investigation was to grab the experts from the national organisation early on, share the evidence we were uncovering and ask them, what do you think? In this way we could jointly start to develop a safety action or recommendation that was smart and pragmatic. This often started fairly quickly but often slowed during the approval process. I accept it is a large organisation with competing pressures and necessary checks and balances, but it felt, from our side, that a higher priority to responding to recommendations would allow valuable learning to be acted on more quickly. In some cases, it felt like everyone quickly agreed about what needed to be done but the final sign off still took an extraordinarily long time.”
HSIB is currently going through an organisational transition to become the Health Services Safety Investigations Body (HSSIB). At the same time, their maternity investigations programme will be formed into a separate body, the Maternity and Newborn Safety Investigations (MNSI) Special Health Authority, with both organisations becoming operational in April 2023.
We asked Keith what difference he thought this change would make, with HSSIB established as an independent executive non-departmental public body. While emphasising that for him HSIB had always acted impartially and independently of its parent body, NHS England, that this change was nonetheless a positive move:
“It’s really important that NHS staff think of us as an independent body. I think most people did, but there were some people out there who thought, ‘hang on a minute you’re part of NHS England, how can I be really comfortable that what I’m saying won’t make its way back to them’. I think the complete legal independence will give everyone confidence to speak to HSSIB.”
He also noted the importance of HSSIB having the legal powers to demand responses from all organisations, commenting:
“There were isolated incidences where we didn’t get the information we wanted in a timely enough manner to make our reports even better and this legislation should ensure that this does not happen in the future.”
During the passage of legislation to create HSSIB through Parliament there were significant concerns raised around proposals to strengthen ‘safe space’ powers for the new HSSIB. Organisations such as Action against Medical Accidents (AvMA), the Parliamentary and Health Service Ombudsman and the Professional Standards Authority for Health and Social Care have highlighted concerns about the negative impact this may have on patient rights and professional duty of candour. Asking Keith about his reflections on this, he said:
“We have legal protection for information that has been given to us and this can only be disclosed through a High Court order, which is exactly how the transport industry operates. I understand the concerns some families may have – that certain witnesses may use this protection to tell us of wrongdoing or criminality, but that’s not the case. If people tell us of something they did that is illegal we are obliged to pass that information on to the appropriate authorities. What some people don’t understand is that information provided under that protected system is used to help us write the report; we just don’t attribute it to a named individual. It enables us to reveal the truth rather than conceal the truth. I do think that’s important. It demonstrably works in other sectors, and I have high confidence this will work in health.”
One of the key areas where healthcare can potentially learn from the approach of other industries such as aviation, and something that Keith called on for in his letter to the Secretary of State, is the creation of a safety management system. We asked him to comment on what this would look like:
“The basics of any safety management system is to have safety objectives, so you set out what you want to achieve. This requires assessment of the hazards and risks and the mitigation to those risks and these need to be transparent. You need an assurance process that constantly monitors the safety performance of the organisation and investigates incidents when they occur. This in turn will drive learning which will further improve safety and crucially embed a safety culture amongst all staff. All of this needs to be recognised at Board level, continually stretching the organisations’s safety objectives."
He also emphasised the importance of Board level leadership in supporting this, saying:
“A safety management system allows safety to be measured and treated in the same way as performance and other targets, and consequently given the same priority. I do not see this happening at present; it sometimes appears to be an irritation or a frustration, rather than something to build on, learn from and be proud of.”
Keith noted that as part of this approach, safety investigations in aviation are an accepted part of the system, understood as being there to improve safety and for the benefit of everyone. Considering what would be needed to move towards this in healthcare, he commented:
“There needs to be a willingness to learn from other industries. In fairness, taking a leap by bringing me in was a willingness to learn, but I don’t see this happening more widely. There are examples where people reach out and see how other industries are doing it but this isn’t done structurally. I did make some introductions with my old colleagues in aviation and I took some of the patient safety team to safety meetings I went to at the Department of Transport. I think having people see examples of how things are done elsewhere, accepting that there are huge differences in the way the operation takes place, is incredibly valuable.”
Turning back to Keith’s letter to the Secretary of State, we asked him about his comments on the lack of interest in the activity and potential of HSIB from successive NHS leaders. He acknowledged this, stating:
“I was frustrated that some of the most senior people at NHS England did not appear to give patient safety the recognition I believe it requires.”
Considering DHSC, he said that initially he had met with Jeremy Hunt regularly and credited him with driving much of the safety agenda, but noted that since his departure that attention had not been replicated. Highlighting the difference with aviation, he commented:
“When I was in the Department of Transport, I regularly met with the Secretary of State. Just the fact that others in the organisation see you invited into the top office and having a chat sets a mark of the importance that is being set. Latterly, this didn’t happen in the DHSC and, unsurprisingly, the focus then moves elsewhere. It’s not personal but, as I said in my letter, you cannot delegate safety down the line. There are some key Chief Executives in the airline world and you can see the differences they made even within a safety management system. If you get someone at the highest level absolutely wedded to safety it really does motivate the workforce in that particular direction.”
In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed. This comes at a huge financial cost, with the Organisation for Economic Co-operation and Development (OECD) estimating that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending. Given this context, we asked whether Keith found it surprising that patient safety isn’t treated as a higher priority. Reflecting on this, he said:
“A safer hospital is a cheaper one to run. It’s obvious as is the fact that people die in hospitals, that’s the nature of the sector. However, a large number of these deaths are avoidable. However, unlike aviation, these avoidable deaths tend to happen individually and do not grab the headline attention that happens with a major transport disaster. This makes it difficult to galvanise leadership into seeing this as a massive problem. If 11,000 people died in one day in one hospital it would be seen as catastrophic, but it doesn’t happen like this, and this is something we have to contend with. This is why I keep coming back to the need to have a structure in place that continually assesses and mitigates risks.”
Finally, we noted that this year a new Chair for the NHS was appointed, Richard Meddings, who like Keith was not from a healthcare background. We asked Keith what key takeaway message he would give him about improving patient safety healthcare and the need to create a safety management system:
“People come into the industry and are not really aware of what it is [a safety management system] and what it could look like and the fact it exists. In the airline industry it became a legal requirement for every airline to have a safety management system. I would mandate it within an organisation. All the information is out there across different industries, and it can be started in a very simple form. It’s about opening people’s eyes to it and that it exists and getting the commitment and engagement to make it happen amongst everything else the healthcare system is trying to do. Not just opening their eyes, it also needs lateral thinking.
With regard to the International Civil Aviation Organisation, it has published an annex for a safety management system which could serve as a starting point for healthcare. Many entities will have most of the elements already in place, but a safety management system will bring these together in a structured way and allow pragmatic action on the insight the system provides. If its embedded properly if will force you to act.”