Chapter 7 Relegated to the back office

Air Accidents Investigation Branch inspectors, usually airline pilots, are regarded in the industry as credible and trustworthy: it is a role that is seen by many as the pinnacle of their career

  • Professor Graham Braithwaite of Cranfield University (PASC 2015)

This is what is so very badly needed – for the role of an incident investigator in the NHS to be seen by all as at the pinnacle of their career.  What this does is put back pride in the role, and build respect from others and for themselves.  This respects that fact that incident investigation is not a target to be complied with or a bureaucratic exercise – it is a vital way of learning and requires a vast amount of knowledge and skill.


Incident investigators in the health service often are fairly junior, have had no formal training on incident investigation and lack the necessary ‘power’ to make changes in their organisation.  They are constrained by timelines and the quest for completing the investigation is the aim not the learning; the final report is seen as the end product not the start.

As we know – incident reporting systems are drowning in reports and investigators in the NHS do not have an army to examine the huge number of incident reports they are faced with – they are more likely to be confronted with an army of inspectors instead.

The function of a risk manager / investigator has shifted from finding out stuff and fixing it to meeting the needs of external inspection and scrutiny.

The skills and tools needed are consistently under used and their potential under realised and, dare I say it, with the ever increasing emphasis on quality improvement we are in danger of losing our way and relegating these key components of safety to ‘the back office’ and being simple administrative tasks.

If you want to learn more (apart from in the book) you can find some fantastic examples across healthcare and other high risk industries as well as lessons from sports science such as the ‘marginal gains’ concepts used in particular in elite cycling in Black Box Thinking by Matthew Syed published in 2015 by John Murray Publishes.

The chapter was written just as the Healthcare Safety Investigations Branch was being set up.  Since then they have appointed a lead (Keith Conradi) and a team of investigators together with an advisory group.  They started formally on 1 April 2017 and have started their first investigation.

I look forward with excitement and anticipation as to see whether this branch will go a long way towards raising the importance of incident investigation and the role of investigators so that they are truly seen as at the pinnacle of their careers.