The Health Safety Investigation Branch (HSIB) is England’s independent national investigator for patient safety. HSIB investigates serious patient safety risks that span the healthcare system, operating independently of other regulatory agencies. It aims to produce rigorous, non-punitive, and systematic investigations to develop system-wide recommendations for learning and improvement and to be separate from systems that seek to allocate blame, liability, or punishment.
“Our mission is to improve patient safety through professional investigations that do not apportion blame or liability.“
This channel 4 report shows that there has been bullying in HSIB maternity – set up to investigate issues in patient safety – mother and baby.
A report into HSIB sparked by a formal complaint, “I have never seen so much evidence of systemic bullying over such a period of time in an organisation with so little being done to address it… I am also concerned by the number of times discrimination against women is mentioned.”
Another report by the King’s Fund, a think tank to look into leadership and culture, including the maternity programme, “Bullying, sexism, racism and other forms of discrimination and unprofessional behaviours appears to be prevalent and tolerated – this goes right to the top of the organisation.”
HSIB responded, “We have addressed any feedback received and made improvements to our maternity programme and how it functions. We have brought in a new leadership team and tackled issues around company culture to ensure all staff feel fully supported in the work they do.“
Dr. Dawn Benson (an HSIB national investigator 2018-2023) told Victoria Macdonald channel 4 News that staff feel bullied and intimidated when they attempt to raise an issue. Some of those concerns have been normalised. She also said that using clinical advisers for the maternity reports rather than safety experts meant that wider problems within the trust or in the health care service were not picked up. “This often leads to reports which suggest that responsibility for outcomes lie within the clinical practice of individuals and teams and fail to consider systems of work which contribute to the outcome.”
Victoria Macdonald said never has she had so many whistleblowers from an organisation come forward, but these did not want the organisation ended; rather, their concerns were about its potential for good being blocked.
This has gone on for years; one can’t help but wonder how many patients and staff have been damaged as a result, and it is no wonder that recruitment and retention are so problematic in maternity.
Bullying is not a peripheral issue – it’s central because it’s been used here to cover bad practices. A health service in which people are afraid to raise issues is one in which patients will continue to die unnecessarily.
My problem is the arrogance with which HSIB’s current management responds. “We have brought in a new leadership team – who? Has HSIB retained any of those accused of bullying? Or any of those who turned a blind eye? HSIB stated, “We are proud of what we have achieved in maternity care, in particular, the thousands of parents who have been helped by our reports.” It was parents who alerted C4News to issues with those reports, and I’m sure that ALL of those parents would have been happier if HSIB reports had saved lives by rooting out bad practices across maternity care.