Being an investigator

We often get asked how our investigations differ from those carried out by NHS trusts, or what an investigator does. Some of our investigators explain.

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Craig Hadley: National Investigator

Craig joined HSIB in February 2019 as a maternity investigator, then joined the national investigation team in October 2020. He is a former British Army Aviation Engineer and Defence Air Accident Investigator. He brings a wealth of experience in accident investigation, human factors and system safety.

Human factors looks at the interactions between humans, the tools and equipment they use in the workplace, and the environment in which they operate. System safety is a way of designing safety into and within the equipment, environment and work processes people use.

This is what it is like to be an investigator from Craig’s point of view.

"My role is to gather evidence about an incident to understand ‘what’ happened. I speak to staff and families to identify the specific circumstances, processes and systems that were in place when the incident happened – the ‘why’.

Then, taking a human factors and system safety approach I review those circumstances, alongside national guidance and policy, to conduct analysis and produce safety recommendations. These safety recommendations are aimed at stopping this sort of incident from happening again across the country.

The testimony of staff and patients is so important in my role, and because we anonymise our reports people feel secure to be completely open and honest.

As an engineer by trade, it is my inherent nature to understand how systems work and, when they haven’t worked as intended and an unexpected outcome has occurred, to then analyse and understand why. Being a safety investigator in healthcare uses those same skills and inquisitive personality to identify where things can work better for improving patient safety.

"Thinking that I could actually be saving someone’s life by doing an investigation and making the right safety recommendations is incredibly motivating, and is the reason I love my job."

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Clare Pagett: Maternity Investigator

Clare joined the maternity investigation team in June 2018. She is a midwife. She brings a wealth of experience in all aspects of maternity care, governance and clinical leadership. This is what it is like to be a maternity investigator in her own words.

"I love being a maternity investigator. It’s so interesting to work with people with such a wide range of professional backgrounds from so many different sectors. This gives each team a strong mix of clinical experience, knowledge and an ability to bring fresh thinking and insight to each investigation. We have all had intensive training in order for us to take a systems approach to an investigation and we also have access to expert advisors from various specialities who can help us.

"One of the most rewarding and vital elements of the role is when I work with families. Hearing about their experiences and perspective and then supporting them throughout the investigation is extremely fulfilling.

"Our investigators also take time to work with trust staff. We establish the facts and understand what it is like for them to work in the maternity service and wider NHS system.

"It is a great privilege to work in this role as I feel I contribute to making a real difference to improving safety for babies, parents and families."

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Jas Palak: National Investigator

Jas joined HSIB in 2019 and felt he wanted to use his skills and experiences to make maternity care safer.

"I come from a diverse background as a professional investigator, having worked across a wide range of safety-critical industries including automotive, rail and aircraft production. My role requires me to collate the facts of a case, in order to assess foreseeability and systemic risk. The aim is to understand why an incident occurred and how harm can be prevented in the future by creating safer systems of work.

"One thing that is very important to me is when we conduct our investigations we don’t attribute blame or liability. I find this enables staff to open up about what has happened and we can get to the truth, which can ultimately minimise the likelihood of a similar incident recurring."

"Being trained in human factors and safety science I really enjoy my role as a maternity investigator, because HSIB looks to bring an entirely new approach to the investigation of healthcare safety incidents.

"I find it very rewarding to work closely with patients, families and healthcare staff and I hope the report I produce can provide a positive outcome to sometimes extremely difficult incidents."

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Nikki Crust: National Investigator

Nikki is a national investigator with clinical frontline experience. While carrying out her role as an investigator, Nikki also returned to the frontline during the COVID-19 pandemic, helping to provide swift learning to the healthcare system and practical care to patients. This is her story.

"A registered nurse by background I wanted to help on the frontline as my Trust was facing unprecedented demand on its services due to COVID-19. Fortunately, HSIB made it easy for me, and I returned twice during wave one and two.

"It was a time of great uncertainty, with families anxious at not being able to see their loved ones in hospitals. To help alleviate the situation I helped develop a family liaison role in critical care. This involved providing open and honest information to patients’ families on a regular twice-a-day basis to keep them updated.

"I worked closely with the senior clinical team in critical care to take the initiative forward and developed the service to meet the needs of staff, patients, and their loved ones. I simplified complex clinical information and gave updates in a professional and sensitive way so that relatives and carers would understand and feel able to question what was happening.

"COVID-19 is a terrible disease, the effects of which I have seen at first hand, but my colleagues in the NHS responded and adapted to meet the challenge. In my hospital we developed the role of the nurse beyond traditional boundaries using technology to positively impact on the patient and next-of-kin experience. We built relationships with families so even in the most distressing times difficult conversations about end-of-life care could be as compassionate as possible. Nurses took on this role, something they normally wouldn’t do, which reduced pressure on consultant leads.

"Feedback from colleagues, patients and their friends and family members has been incredibly positive, even from those who sadly lost their loved ones. I am pleased to say that this service continues while visiting is being restricted."