Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Ciaran Mulgrew, chairperson; Maureen Edwards, interim chief executive; Chris Hagan, medical director; and Tara Clinton, interim director of anaesthetics, critical care, theatres and surgery. Thank you very much for coming to the Committee today. I will allow you, if you want, to make some introductory remarks, and we will then take questions from members.

Mr Ciaran Mulgrew (Belfast Health and Social Care Trust): Thank you, Philip. We were happy to get an invitation to appear before the Committee. Since the independent review was reported and since the team came back to us, there has been a lot of comment about the cardiac surgery unit and the Belfast Trust in general. Not all of that has been accurate, and we are pleased to have the opportunity here to discuss things.

The good news is that the independent review team found the service to be safe, and that is the number-one priority. The reality is that some appalling behaviours were referred to, and there is no point in not being open and frank about that. Maureen will go into that in more detail in a moment. We are here today to be publicly accountable for the actions of the Belfast Trust with regard to the issues around the cardiac unit. We need to be accountable to the 650,000 people who live in the Belfast Trust area and to the 1·9 million people who live in Northern Ireland who rely on the cardiac surgery unit for a regional service.

We have highly skilled surgeons, all of whom remain in work and performing surgeries in what has been a difficult period for them, and they are to be commended for that, as are all the other clinical and non-clinical staff, who, in the cardiac unit and throughout the trust in general, continue to put their patients first. Our clinical outcomes are top-class. We regularly have patient satisfaction scores at 99% and 100%. If any of us were unfortunate enough to require cardiac surgery this evening, the best place that we could go to get it is the cardiac surgery unit in the Belfast Trust. You would be lucky to be brought there versus any other unit on the island of Ireland or in the British Isles.

We are here to reassure the public. Some 23,000 members of the public work in the Belfast Trust, and they deserve to be reassured that the organisation learns from issues and that we try to create a working culture in which people are not just free but encouraged to speak up and will not be penalised for doing so. The fact that 70 of our staff were willing to come forward and speak to the independent review is a sign that we have made progress in that area. In the past, that did not happen.

I will pass over to our trust chief executive, Maureen.

Ms Maureen Edwards (Belfast Health and Social Care Trust): Thank you. I will provide a bit more context for the discussions today. The Committee will know that an independent external review was commissioned by the Public Health Agency (PHA) and the strategic planning and performance group (SPPG) in early 2025 following concerns raised with the PHA, primarily about the safety of the cardiac surgery unit. The team of reviewers — they have a lot of experience in the UK and have done similar reviews, including reviews of cardiac surgery units — began work in early February with two principal aims: first, to examine processes, governance and outcomes in order to provide assurance that the cardiac surgery service was safe; and, secondly, to look at culture, teamwork and behaviours and recommend any additional actions that would facilitate high performance in the service.

With regard to the culture piece, it was not an investigation or an inspection. The review team told us that they aimed to get a temperature check, at a moment in time, of staff feelings and experience and any fears or concerns that they had. The team had planned to meet about 20 staff. After discussion with them, we agreed to extend the duration of the review to allow them to speak to a lot of people who had put themselves forward, allowing the team to speak to 70 staff. It was important for us that as many voices as possible were heard, and it reflects the confidence that the staff had in the process that we had all agreed to and that they believed that there would be action.

The report was issued to the trust on 12 May, and the review team came over to present their findings at an extraordinary meeting of the trust's board on 15 May. The headline in terms of safety, as Ciaran said, was:

Our National Institute for Cardiovascular Outcomes Research (NICOR) data, which is the cardiac surgery outcomes data, was exemplary, the review panel said. That day, the panel told the trust's board that we have wonderful staff and that our patients get a great service, and that is consistent with the patient experience feedback that we get and the many compliments that the cardiac service receives. However — this is why we are here today — they also told us that the majority of staff whom they spoke to expressed significant concerns around culture and teamwork. They cautioned and we fully accept that, whilst we currently have a safe, high-quality service — that is undisputed — cultural issues left unresolved pose a risk to patients and quality over time.

The report concluded that the Belfast Trust has world-class cardiac surgery premises and that we have done a lot of work since the Royal College of Surgeons (RCS) reported in that space and have made good progress on many of the RCS report recommendations, despite the disruption caused by COVID, which impacted on our ability to bring forward the cultural issues at pace. The team noted that those achievements were a testament to management in the unit. However — again, this is the most important outcome — they concluded that cultural issues and poor behaviours in the cardiac unit have persisted for some time and are still prevalent. In getting to the nub of what those poor behaviours are, the review team were clear that it was a pattern of behaviours on the part of a very small number of cardiac surgeons. Those few consultants were causing discomfort and distress to too many staff, and, in particular, we heard that junior medical and nursing staff felt unsafe and fearful of raising points of concern about practice and behaviours. Included in the report were a number of direct quotations, the most powerful of which you will have heard in the media over the last few weeks.

The trust board discussed the review's findings and recommendations in some detail and has fully accepted all of its recommendations. There was an overwhelming sense of shame at the trust board, particularly around the fact that staff in our unit do not feel safe to raise concerns, which we know, if unaddressed, will pose a risk to those in our care. I should say at this point that the trust was aware of and addressing disputes of poor behaviours in the cardiac unit. We had HR and legal processes ongoing. However, the evidence suggested that those issues were confined to and impacted a small number of surgeons and a few related staff. We were not aware of the significant impact that the behaviours of those few staff were having on the wider team and the distress that it was causing them, which has now obviously become evident in the report.

The trust board, as you would expect, was shocked and appalled at the behaviours of some of our staff, and we are sorry that we have not been able to address the issues. Normally, with external reviews in this trust and other trusts, the full report would not be shared beyond management level, and only high-level findings and recommendations would be shared with wider teams. However, given that this itself was a criticism in the report, given the work that we are doing around an open, just and learning culture, given our desire to be as open and transparent with a group of staff who, we recognise, have given up considerable time to feed into the review and given, of course, the severity of the issues highlighted, the trust board took the decision to share the full unredacted report with all of the staff in the cardiac surgery unit who wished to see it. We held three town hall meetings — we call them "open forum" meetings — the week after the trust board meeting, and around 150 of our 250 staff attended those meetings. At the meetings, the chairman and I presented the findings and recommendations, and I used almost word for word the presentation that was delivered by the review team in all of its detail. We outlined the actions that had already been taken and the actions around the next steps and implementing all of the recommendations, which, obviously, are at an early stage, but we shared all that we could. We asked for input, and we got some feedback about team building etc that we have fed into the action plan.

At those meetings, we were absolutely clear with staff that they should not have to train or work in that type of environment and that behaviours such as those would not be tolerated in the future. We have given our strong commitment to them that we will now do whatever we can and as quickly as we can to ensure that staff are not only encouraged but supported and feel safe to speak up, if they have concerns about safety or behaviours. We can then address those concerns.

Following the open question session at the town hall meetings, each member of staff was given the full unredacted report. In the last few weeks, given the attention that this has attracted, we have been asked on various occasions whether issuing the full report rather than headline messages and recommendations was a good idea. Do I regret the distress that has been caused to our staff not just in the cardiac surgery unit but in other services in the past few weeks and the effect on the confidence of the public and on patients and their families at a time of heightened anxiety? Absolutely. We absolutely regret the distress that it has brought. However, hiding from the issues will not solve the problem. Staff in cardiac surgery told us at the town hall meetings and on many occasions since that what we have done is a step change, that we have broken a cycle that they did not agree with and that they appreciate what we have done. They agreed to judge us on how we implement this and the actions that we take. We have given a clear commitment. The transparency has resulted in criticism, which is unfair on the overwhelming majority of the 22,000 staff in our trust who have not behaved and never would behave inappropriately. However, we will truly move on from these long-standing issues only if we put all of our cards on the table, get it all out there, fix the problems that have happened and are held to account by, primarily, those in our trust and, externally, by the SPPG and the Department.

In giving staff the full and unredacted recommendations from the report, we have given them full sight of what the leadership team has undertaken to do. They will now be in a position to judge us. A cardiac surgery oversight group with trust board representation has been established. We have developed a comprehensive action plan with clear actions, lines of accountability and timescales to ensure that not only the recommendations of the recent review but any recommendations from the previous Royal College of Surgeons review that have not been implemented in full are now implemented as quickly as possible. We are conscious, of course, that it takes time to sustain changes in culture. We have already had meetings with PHA and SPPG colleagues, as well as with our trust board, to take on board any comments on our first draft of the plan. It has now been submitted to the Department, the SPPG and the PHA. The action plan will be updated on a weekly basis by Tara and the oversight group. We will report formally on progress to the trust board and thereafter to the PHA and the Department every month. We are happy to be held accountable for actions and progress.

The oversight group will be supported and challenged by the external support that was recently promised by the Minister. That is very welcome. As you will hear from Chris in a minute, we have had external support. We benefit from external support from other trusts that have gone through similar issues in cardiac surgery or other services. We will learn. That will strengthen the supports that are already in place and, hopefully, ensure that there is meaningful change at pace.

There have been a lot of questions over the past few weeks about who knew what and when and about why it seems that issues in cardiac surgery that have been known about for some time have not been addressed. I will hand over to Chris, who will take you through a timeline, starting with the issues that gave rise to the Royal College of Surgeons report.

Mr Chris Hagan (Belfast Health and Social Care Trust): Thank you for asking us to come here today. From our perspective, the issue began in 2019, when some of the team approached the former medical director and me, as the deputy medical director, with concerns about bullying in the team. It transpired that it had been going on for many years in that team. It was an isolated team in some ways; it sat by itself in its own theatre area in the Royal at that time. We chose to try to address the issue. That is why we invited the Royal College of Surgeons to come in January 2020. It gave us verbal feedback in March — you will remember that March 2020 was when the pandemic started — and said that the unit was safe, but it raised significant issues around the culture in the team and the poor treatment of trainees. We were provided with a report in June 2020 in which there were 37 recommendations. I will break those down into four main themes. There were cultural issues around bullying and allegations of racism in the unit. There were issues around local leadership and management; it was recommended that support was required. The report also stated that there were systems and processes in the unit that were somewhat outdated. It suggested that the thoracic unit be split from the cardiac unit. It made recommendations about the facilities and about the pathways for patients through the unit, including the critical care unit. Issues were also raised about financial probity in the team.

I met the team, along with the chief executive, in June and gave a presentation, sharing the report and highlighting the concerns around bullying and poor culture in particular. We reminded team members of the evidence of instability and how that can affect patient safety, so there was no doubt in the team about the behaviour that was expected of them. At the time, we were aware of one surgeon who was bullying trainees. He was fully restricted in dealing with trainees at that point, and he subsequently left the unit. We brought in an outside clinical director (CD) to run the unit who had lots of experience of being a clinical director, and a very senior vascular surgeon also came into the team to support it. We engaged with the Leadership Centre for mentoring and support.

On Friday 23 October, we held what is called a "risk summit". A risk summit is when we bring together stakeholders who have an interest in the unit. That included the Department of Health; the Public Health Agency; the board at the time; the Northern Ireland Medical and Dental Training Agency (NIMDTA); practitioner performance advisers (PPAs), who provide external advice to medical directors like me about managing concerns; the General Medical Council (GMC); the Regulation and Quality Improvement Authority (RQIA); and Queen's University. They supported the trust's approach in developing the action plan and in the management of concerns, particularly around the treatment of trainees and other staff. They noted that the clinical outcomes were excellent — that was a main feature of the report — and raised no issues about the treatment of nursing staff. We then went through multiple disciplinary processes in the team, due to the concerns that team members had raised against each other, with multiple HR processes. At the end of that, we were able to recruit two new consultant cardiac surgeons into the team, due to the retirement of two individuals. We had an investigation into racism, which concluded that there was no evidence of racism, and there was a Business Services Organisation (BSO) counter-fraud investigation, which held up no concerns of fraud.

On 5 February 2021, we had a second risk summit with exactly the same colleagues from the Department, PHA, the board, NIMDTA, GMC and RQIA. At that point, I and others highlighted the ongoing difficulties with interpersonal relationships among a small number of the team that were making it difficult to improve team dynamics. NIMDTA and the GMC warned us that, if the team dynamics did not improve, they would put the unit into what is called "GMC enhanced monitoring" for training. Later in February, they did that, because of their concerns about the environment around trainees. Later that year, we began a staff experience survey to get feedback from our staff on what it is like to work in the Belfast Trust. We linked in with Northumbria Healthcare NHS Trust, where there is a lot of expertise in doing that. That was done to get a better understanding of how staff felt working in our organisation. We also had an RQIA unannounced inspection of the unit in December 2021.

On 3 January 2022, we had a further risk summit. Again, the same partners were present. At that meeting, evidence of good progress was recorded: 27 of the actions were complete, nine were under way and one had not started. It is important to remember that this all happened during the pandemic. I was the lead for the pandemic response, and I was leading on this response as well. We had had consultant listening exercises and trainee listening exercises, and a new leadership team was in place with a new CD, four clinical leads and a new chair of division, who sits above that. We managed to separate the cardiac and thoracic teams, which was not straightforward, because we had surgeons who wanted to continue with mixed practice, and we recruited new consultants. We improved our governance arrangements for things such as monitoring complications in the unit, which is not done in all cardiac units across the UK, because it is not part of NICOR reporting. The variable life adjusted display (VLAD) reports, which give individual consultant performance, were shared with the consultants so that we could monitor individual performance. We also had live monitoring of our waiting lists — if you remember, a lot of patients were waiting for surgery at the time — which meant that we could identify who most needed surgery. We also learned lessons from delays in treatment for lung cancer and improved the pathways around that. We audited the lung cancer wedge resections, which showed that there was no issue with that area. Our patient experience rating remained at 98·6%. We managed to relocate the whole unit into a new theatre complex during that time. Towards the end of 2022, we had managed to get up to 850 cases per annum. The spells per annum (SPA) figure for the unit is 950, so it is really impressive that, in the middle of the pandemic, we got back up to that. At that point, it was felt that no more risk summits were necessary due to the progress.

Later that year, we also launched the Speak up for Safety campaign in the trust, which encouraged staff to speak up if they had concerns. In 2023, Peter McBride came into the trust to do a listening exercise and explore routine openness. He made a presentation to the trust board. In April 2023, due to ongoing concerns about poor culture in the cardiac surgical unit, the board asked Peter McBride to come in, mediate and work with the team and try again to continue to improve culture.

Towards the middle of 2024, in July, the GMC and NIMDTA both recognised that the training experience for trainees had improved significantly, and they took us out of enhanced monitoring. We were aware that cultural issues continued in the team among, as Maureen said, a small number of consultants. We linked in with a trust in England that had had similar problems in its cardiac surgical unit to seek advice and guidance and make some linkages. Through that, we heard of some of the members of the review team. At that point, it said to us that it would take at least five years, if not more, to change culture in the unit. Unfortunately, cardiac surgery seems to have difficulty around culture. We are not the only cardiac surgery unit in the UK that has had difficulties with culture. I do not need to name the units, but you can find them if you go on to the web. The difference between the unit that we linked with and our unit was that its outcomes had suffered because of poor culture. Our outcomes were maintained. As Maureen said, we then commissioned the review of the surgical unit by the PHA. At the time of the review, we also did listening exercises with our trainees, as did NIMDTA, and we identified one surgeon who was named by the trainees as someone who bullied them. We restricted him from access to trainees also.

We have already talked about the town hall. I will make a few more points. We have had two external reviews of the unit in a five-year period, and both of them concluded that the unit is safe with excellent clinical outcomes. That is a really important point for me to get across. We completely accept that the behaviours of a small number of the team are completely unacceptable, but the unit has made good progress in other areas when it comes to getting rid of enhanced monitoring. I met the entire team of consultants and reminded them of the importance of their behaviour. I did a town hall with 200 medical staff yesterday and reminded them of the importance of that. It is vital that we retain public confidence in the service. That is vital. It is an excellent service that delivers excellent clinical outcomes, and we need to remind ourselves of that.

It is also important that we do not undermine confidence in the Belfast Trust and its ability to deliver high-quality, safe care. We have at least 50 clinical specialities in our organisation that deliver amazing care day in, day out. Unfortunately, the media attention around this affects the confidence of staff as well. It is really important that staff feel confident and supported in coming to work and that we identify the great job that they do. Some of those people are your constituents. It is really important that we acknowledge and recognise that. We have a duty of care to our staff as well. I offer an open invitation to any of you to come to our organisation and see what it is like. Come and stand in the emergency department (ED) and see what it is like for people who work in that environment. Come and see the excellent clinical services, such as our stroke, cardiology, surgical, paediatric and oncology services. Come and see what it is really like. Talk to staff. It is an open door.

There has been some criticism about leadership. Sharing the report and being open and transparent about the things that we have done is leadership in action. We have not shied away from anything. We have taken these things on and tried to fix them. Things do not always work out the way that we want, but we did this in the middle of a pandemic. Sometimes people forget the efforts that we made. We have to celebrate some of the really good things that we did. We will hold our hands up and say that there is still an issue with a very small number of surgeons in that unit, and we will try to address that. We have a comprehensive action plan. Our patient feedback remains excellent. The trainees have reported back to me verbally that they have noticed that the environment is improving, which is really great, but there is another listening exercise happening in the next few days, and we are meeting NIMDTA to get an update on its view of what it is like. The GMC has written to the trust and is not going to put the trust back into enhanced monitoring, because it acknowledged the actions that we have taken to date and recognises that there are still local measures that we can do to manage this. We have put additional support into the multidisciplinary team meetings, because we see that as a particular risk for the service. That is where people come along and are able to discuss complications in a safe way. I am a surgeon, and I know that, if you cannot talk about your complications in a safe way, that is unsafe, so we are putting additional support into that.

Two of the surgeons in the team are in the top 5% of cardiac surgeons in the UK, according to the NICOR data. That is a really important thing for you in understanding how good the team is. Since the thoracic team was separated from the cardiac team, it has absolutely thrived at innovating. It wants to do robotic surgery, and we need to support those people to do those great things for the people of Northern Ireland.

There is an issue about instrument-throwing in the report. That is under investigation. We have weekly oversight group meetings. We have Mediation NI working with the team. I do not know whether any of you are familiar with it, but it did a lot of work during the Troubles. It is working with the team, and, hopefully, we will get some resolution around that. However, I need to be open and honest with you and say that some of the surgeons still continue to raise complaints against each other. Despite everything that we have heard, they continue to raise issues against each other. It is really difficult to manage a very small group, but the rest of them come to work and want to do their best. The Nursing and Midwifery Council (NMC) has come and met the nursing staff, and the GMC will come and provide an open session. We are planning some other cultural work with the team.

I am happy to take questions.

The Chairperson (Mr McGuigan): Thank you very much. I will go straight to members' questions.

Mrs Dodds: Thank you, Chair. Gosh, I was expecting you to ask questions first. I appreciate the opportunity.

Thank you for coming. It is really important that we have an open dialogue. First, in the interests of openness and transparency, will you release to the Committee the recommendations from the Peter McBride report of 2023 along with the document that you have released? I am sorry, I will qualify that: the Minister said that it was not a report but a presentation.

Mr Mulgrew: That is correct.

Mrs Dodds: Will you send us that presentation?

Mr Mulgrew: I have no problem in sending you that.

Mrs Dodds: That is excellent. Thank you. I was told that —.

Mr Mulgrew: That report never mentioned cardiac services.

Mrs Dodds: It would be excellent just to have a look at that. Openness and transparency is really important in this issue.

As you can see, I have been reading the conclusions and recommendations of the report, and I do not really want to focus on the behaviour, because a lot has been said about that and I trust that it is being dealt with. However, there are some really important conclusions and recommendations in the report that will take us forward.

Dr Hagan, you mentioned that surgeons in the unit are still reporting each other. You have to help us to understand that. Conclusion 6 states:

Conclusion 8 states:

Was the threat of referral to the GMC from management or from other surgeons? I presume that you, as medical director, know. I am just trying to understand what MHPS is. I know in general terms what it is, but, for my sake and maybe for everyone else's sake, it would be helpful to know specifically.

Mr Hagan: In my role as medical director, I am also the responsible officer, so I have a statutory role to ensure that doctors are appraised and revalidated and not only to ensure that good clinical governance is in place but to manage any concerns about the health, conduct or performance of a doctor. Doctors have a unique maintaining high professional standards (MHPS) framework, which is how concerns about doctors are managed, and that is in their contract. However, there is an ethos about how you can apply that.

We have changed considerably the approach to MHPS in the past five years since I came into post. For example, when I came into post, we had 1,400 permanent medical staff and 600 or 700 trainees, and over 100 files were open on doctors. Today, there are about 15. We went from 7% to 8% of the medical workforce in some sort of process to less than 1%. There is nobody in a formal MHPS process at the minute. There are some doctors with restrictions, invariably due to health or something like that. With regard to what you read out from the report, there was certainly nothing from the medical director's office threatening individuals in that team with an MHPS or GMC referral. I looked at the most recent data on GMC contact from the medical director's office, and it averages about four referrals per annum since 2020.

We have a close working relationship with the GMC. I am the link with the GMC in the organisation, and I work closely with the GMC employment liaison adviser (ELA). I discuss not all concerns but any that meet, I think, the threshold for discussion with the GMC ELA, and we will determine whether a concern can be managed locally or might need referral to the regulator for further discussion. For instance, things that come across my desk might include information about a doctor convicted of drink-driving: I would have to discuss that with the regulator because there was police involvement.

Mrs Dodds: I accept that. You said that that has improved over the past five years. Was the figure of 100 in the Belfast Trust in the MHPS process higher than in other trusts in Northern Ireland? I know that yours is a much bigger trust, so perhaps you could answer in percentage terms

Mr Hagan: It is difficult to get accurate data on that. The trade unions, the BMA, the Hospital Consultants and Specialists Association (HCSA), the GMC and Practitioner Performance Advice have all acknowledged that there has been a different approach to how issues with doctors are managed. In my experience, the most common issue is conduct, usually interpersonal working in teams. Oftentimes, that is best managed in a supportive and kind way rather than through a formal process. Doctors raised concerns about how MHPS was being applied. As an organisation, we have committed to having a review of the application of MHPS going back over a number of years, and Ciaran has commissioned that.

Mrs Dodds: When will that review start?

Mr Hagan: It has only just started.

Mrs Dodds: OK. Conclusion 13 refers to soft forms of bullying, refusing leave etc. It adds, however:

The review, I presume, will be an external review of the process.

Ms Edwards: Industry experts.

Mrs Dodds: That is important in reassuring clinicians that, if they speak up and say that something is wrong, they will not be punished for that.

Mr Mulgrew: May I say something on that, Diane?

Mrs Dodds: Yes, of course.

Mr Mulgrew: The referrals to MHPS are not necessarily referrals by the trust. Clinicians can refer one another to MHPS.

Mr Hagan: The GMC.

Mr Mulgrew: The GMC. That then puts people into processes. That is not the trust taking action against those people in every instance. It may well be that clinician A has a dispute with clinician B, and that is where it ends up.

Mrs Dodds: OK. That is helpful. It would be good to get the Peter McBride report, and we have this report. We also have to remember that this report is up to date. It has just been written.

Mr Mulgrew: It is from 15 May.

Mrs Dodds: This report is still talking about poor behaviour etc in the trust, which is really important.

May I ask a slightly different question? It is now 15 months since the handover of the maternity hospital. What progress has been made in that time on deciding the course of action to get the hospital opened? Where are we now? I thought that you might have said something about that in your presentation.

Ms Edwards: We were limiting the presentation to the cardiac surgery issue, which is what we were asked to do. However, I have no problem answering you, Diane. The trust made a submission to the Minister this week. I understand that he will bring that to the Health Committee to discuss where we are with the maternity hospital. There has been a series of meetings with the appropriate people around next steps on remediation. You will know that there were a number of options. The trust board has agreed the option from the responsible officer group — the water safety group. That was brought to the trust board last week and was ratified. That decision on the next steps has gone to the Minister, but there will be some caveats to that. We are going ahead with one option, but we will keep it under review, given that there will still be concerns. We need to keep satisfying ourselves that the number of contamination events is managed.

Mr Mulgrew: Effectively, three options were considered. The first was localised remediation. In effect, that means that you remove the taps that currently test positive for pseudomonas. The second was that we put in a discrete water system for the —

Mr Hagan: Neonatal.

Mr Mulgrew: — most at-risk neonatal patients. The third option was that the entire water system be pulled out.

The recommendation between our internal people and the independent reviewers was that option 1 was not likely to solve the problem. Option 3 was, in their view, excessive. Option 2, a discrete water system for the neonatal care unit, was recommended as the best option. However, we could be part of the way down that road only to find out that, when we open the system, there are problems that we do not know about at this stage. We might then have to revert to option 3. However, we do not believe that that will be the case. The best advice that we can get from industry experts is that that will not be the case.

Mrs Dodds: I am no expert on this; I am just thinking out loud. For clarity, if you adopt option 2, that would ultimately mean that there was still some colonisation of pseudomonas in water pipes in other parts of the hospital but you would replace the water system only in the neonatal unit. If that is the option that you are going ahead with — I accept and appreciate that you will keep it under review — are you satisfied that that is a safe option?

Mr Mulgrew: The best advice that we have at this stage is that, were we to go to any taps in this Building, for example, we would find pseudomonas. If we apply to non-clinical areas a different standard from the standard that we apply to the neonatal areas, where pseudomonas is much more dangerous, the best advice that we have at this stage is that option 2 is the safest way forward.

Ms Edwards: The full report has gone —.

Mrs Dodds: Do you have a costing for that?

Ms Edwards: Yes. That is all in the full report. The intention is that the Minister will share that. The trust will be happy to come back and discuss that with the Health Committee.

Mrs Dodds: OK. It has happened before — I would not like it to happen again — that we have a discussion with the trust one day and find out about another problem the next day. Are we positive that no more shocks are coming down the line in relation to safety or any of those other issues?

Mr Mulgrew: In an organisation with 23,000 people and a turnover of £2 billion, it is impossible for me, as chair, to say that I can guarantee that everyone is behaving properly. All we can say is that, when issues such as this have come out, we have been open and upfront about it. We have been clear about the standards of behaviour that we will and, more important, will not accept. The key thing is to deal with the problem rather than walking past it. We are being as transparent as any organisation could be, but can I guarantee that someone somewhere is not doing something wrong? I just cannot do that; I do not believe that anybody could.

Ms Edwards: I will add to that. We have strong governance frameworks in place. We triangulate all our data from complaints, clinical outcomes and patient and staff feedback, so we are always on the lookout for something that may be bubbling. We are not aware of anything at the minute.

Mrs Dodds: Every member of the Committee has received a letter from concerned staff of the Belfast Health and Social Care Trust that outlines issues not just in the cardiac surgery unit, which we have talked about here, but to do with a series of scandals in the trust, including Muckamore and neurology. I will read you one sentence from the letter that was sent at 7.30 last night to every member of the Committee:

That is why I asked about the process for maintaining professional standards: it is unusual for us to get a letter like that and for staff to raise their concerns in that way. I have no idea whom it came from, and no one here knows. It is an anonymous letter, but it is signed, "Concerned staff of the Belfast HSC Trust".

Ms Edwards: We do not know whether that is from one member of staff or from 10, 100 or 1000 staff. We had sight of the letter only this afternoon. Yes, there are issues with capital projects, for example, that have been well rehearsed at the Committee. Everyone is aware of the issues — Muckamore and neurology — that you mentioned. Over the 18 years of the trust's history, we have had a number of issues. We are the only trust in Northern Ireland that does the full range of services. You will know from the Ray Jones report, if you are familiar with it, that our trust is probably equivalent to six to eight trusts in England, in that we have the full range of acute and community services, including mental health, learning disability and children's services. Unfortunately, things go wrong despite our best efforts, and, over those 18 years, we have had some serious issues —

Mrs Dodds: I do not want —

Ms Edwards: — which we have identified and addressed.

Mrs Dodds: — to be confrontational. I do not know when you saw the letter, but we got it only last night. We cannot unsee such a letter. We have to act on it. The letter is signed by staff of the trust and talks about:

It goes on to say:

That paragraph ends:

Mr Hagan: Diane, it is really important that I challenge some of those things. The directors in the organisation are extremely visible. Yesterday, I did a town hall event with nearly 200 medical staff. I will meet a group of general surgeons tomorrow. The director of the children's hospital and I met the entire staff of the children's hospital in an open forum a month or so ago. We have changed a lot of our governance processes, with daily escalation to the chief executive, if there is an issue, and weekly live governance. We look at all issues, complaints, serious adverse incidents (SAIs) and unexpected deaths, and we escalate anything that comes from that to the executive team and, eventually, the trust board.

We have safety walkabouts. We are visible.

I found it really upsetting to read the letter, because it does not reflect my experience of working in the organisation, an organisation in which I have worked since 1998 and for which I am proud to work. I am happy to talk to any member of staff about their concerns. It is disappointing that the person who wrote the letter did not put their name to it, because I would love to have a chat with them to find out what their issues are.

You may or may not remember that recommendation 14 of the independent neurology inquiry was that the Department of Health look at governance in the Belfast Trust, and I need to reassure the Committee that the Department was satisfied with the governance in the Belfast Trust. It also commended us on some of the work that we had done to learn about clinical record review and the information that we collect on doctors' practice. Hopefully, that should give the Committee some reassurance.

Mr McGrath: You are back again. Ciaran, we can look back at Muckamore, the problems with the inpatient mental health building, problems with the maternity hospital, delays to the children's hospital, the neurology inquiry and the hyponatraemia inquiry, and now there are the cardiac issues and this letter from a member of staff. Are you — you and your colleagues on the board — fit to govern the trust, and have you considered stepping down?

Mr Mulgrew: First, that is a disappointing question, particularly when you put at the end of that series of concerns an anonymous letter: no one can verify whom it is from or what it says. Secondly, it is a deeply unserious question. You may think that sharpening a stick at both ends and impaling someone's head is the way to solve problems, but that is entirely contrary to being open. We are trying to bring issues to the fore and discuss them. You ran through a series of events that date back 20-odd years. To put them all together in 30 seconds in that way is to totally misrepresent the trust and the people who work there.

Mr McGrath: You have cost the public purse hundreds of millions of pounds through the delays in some of your work, such as the delays to the children's hospital. That is the trust; not you personally. Many of the issues leave staff feeling that they cannot go to work. Staff have approached me about other issues in your trust. It was deeply concerning, if that is the language that you wish to use, to hear you, Chris, talk about there being problems but saying that things are generally grand and you are trying to do what you can. It is as though there is an excuse to let staff behave in the way that they have been behaving. If it were happening anywhere else, the line would be, "The behaviour is unacceptable and needs to stop", but it seems that the line from you is that you will give time, space and opportunity for people —.

Mr Hagan: Colin —.

Mr McGrath: I have not finished yet, Chris. You are giving people time and space to adjust their behaviour when the response should be, "The behaviour stops".

Mr Mulgrew: Colin, biting someone's head off when they are trying to speak is behaviour that should stop as well. Let us hold everyone to the same standards.

Mr McGrath: Sorry, Chair, I think —.

The Chairperson (Mr McGuigan): Everybody will to have to take 10 deep breaths. I am chairing the meeting. We will allow a member to ask questions. I ask that everybody ask and respond to questions in a courteous manner. This is an Assembly Committee, and I want everybody to treat everybody else in a respectful manner when asking and answering questions. There will be no interruptions, and everything will be done through me.

Colin, finish asking your question, and then we will allow an answer.

Mr McGrath: Thank you. The point that I am making is that it feels as though, in the middle of the explanations about the behaviour, there is a "but", as in, "The behaviour is happening, but we are trying to address it. We are getting around to doing it". If this were in any other sphere or they were junior staff in many organisations, they would be told, "If you don't shape up, you'll get out". Here, however, it seems that we have to accept that we have to mollycoddle the behaviour.

Chris, at the beginning of the session, you said that the process began in 2019 and that the behaviour had been going on for a number of years prior to that. That means that the behaviours have been going on for coming up to 10 years.

Mr Hagan: Colin, I would like you to moderate your language a bit. I do not talk to you like that, so please talk to me respectfully.

What I said at the start is that 2019 is when I first became aware of it, OK? I did not become medical director until 2020. I outlined to you in great detail the steps that we took to restrict surgeons, and I told you about surgeons leaving the unit and the recruitment of new surgeons. Another new surgeon is coming soon. Multiple disciplinary HR processes have taken place, but we also had a responsibility, which you need to understand, to deliver a cardiac surgical service to the people of Northern Ireland. We had a commitment to deliver 950 cases per annum to ensure that people in Northern Ireland received high-quality cardiac surgery. That team delivered that.

Where you are leading up to in your questions, I think, is whether we should get rid of people. The problem with that argument is that it makes it harder to deliver a safe cardiac surgery service. We have an obligation to the people of Northern Ireland to deliver a safe cardiac surgical service. What I hope that you can take from the session is that two external reviews, five years apart, confirmed that the service is safe and delivers high-quality care. Importantly, however, we took measures, such as bringing in Peter McBride to work with the team, mediate between people and try to improve working relationships. We have restricted another surgeon because of their behaviour and how they treated trainees. We have taken action, but we have tried to maintain a service as well. That is really important: if we had dispensed with surgeons, you would probably be criticising me for not delivering a safe service, because we would not have been able to meet the SPA.

Mr McGrath: I accept your point, Chris, but I do not like where it leads us. It leads us to the conclusion that staff can behave in whatever way they want, because the overriding concern is the delivery of a safe service, not how they behave. That may create a culture where staff feel that their behaviour is permissible because they are too important to be moved on and they are irreplaceable. If that is the attitude and culture in the organisation, it leaves us in a worrying situation. I accept that it is a conundrum; I get that. However, the message that goes out to the public is that, if you are in an important role, you can behave in whatever way you want, because we will have difficulty replacing you. That provides an excuse for that behaviour. That is difficult to hear.

Mr Hagan: I am not saying that. We have tried very hard to manage very poor behaviour. We have taken disciplinary action against individuals, as I described. We have had discussions with regulators etc. Those are confidential HR processes, and I cannot discuss them in an open forum such as this.

Ms Edwards: May I come in? We absolutely are not saying that certain staff members are treated any differently and that they can get away with things. We are absolutely not saying that. If people meet the threshold for disciplinary action, they will be disciplined. The message coming out of the report, which is our focus, is that staff feel unsafe raising concerns. That is where all of our efforts are going, because they should not feel unsafe. Once those concerns are raised, we will deal with those.

From the report, we found that, where issues had been raised, we have dealt with them, as Chris articulated, or are dealing with them. There are ongoing processes. We did not know about some of the things because — this is important to us — as the review tells us, staff were afraid to raise those concerns. We have now committed to staff that we want them to feel supported. We have put in additional measures over the past couple of weeks. We have provided occupational health connections. We have worked really hard with trade union colleagues and will continue to do so to make sure that staff raise issues. We have given a strong commitment that, where such issues are raised, we will act on them, regardless of who it is. There are different mechanisms for following up on conduct, such as, for example, through the MHPS for doctors. That does not mean that we will not take action.

Mr McGrath: I hope so. The letter and the two or three other instances that I know of send the repeated message that staff do not feel that they can speak up. I hope that we get the message out that the trust board and senior management of the trust are saying, "If you feel that your bosses in the service are going to give you a hard time, bypass them and go to the senior management team to report". Some of the difficulty is that a person might have a problem with their manager, but the manager could be best buddies with their manager. Staff might feel that going more than one level above would cause issues. Having in place a system whereby staff can bypass people who are causing the problems would be a good help.

Ms Edwards: We absolutely agree with that. We have a whistle-blowing process in the trust that does exactly that. It bypasses that level. That is what is used in Northern Ireland. The review recommended, and we are absolutely taking this on board, a model in England that seems to be better — Freedom to Speak Up — and that is not in Northern Ireland at this point. We will follow that up. We will take the key elements of the success factors there, including, for example, Freedom to Speak Up buddies, and we will start a campaign.

I completely agree with you that the big learning for us is about how we can know what to fix if we do not know what it is that we have to fix. It is unfair and indefensible that we have created and allow to go on an environment in which staff do not feel that they can do that. We are absolutely 100% behind that, and so is the trust board. We accepted all the recommendations, such as learning from Freedom to Speak Up. We believe that the additional support that the Minister has promised — someone with vast experience in England — will bring that learning. We are absolutely happy to take that learning from them, and we will be happy to be challenged on it.

Mr Mulgrew: First, Colin, with regard to people speaking to their managers or being afraid to speak to people, we have introduced a system whereby that can be done anonymously through a QR code. Anyone can scan the QR code and get straight through, and nobody knows who has said what. That is a step in the right direction.

We are a business that has a turnover of £2 billion. The anonymous letter may well be from one individual who has a personal gripe. You have no way of validating it, nor have we. There is enough data that we can talk about — we can verify whether it has been provided by independent sources — and we should concentrate on that until we are able to establish whether that letter is legitimate or is a personal grievance. We just do not know at this stage, so it is not reasonable that an anonymous letter should set the tone for the discussion going forward.

The Chairperson (Mr McGuigan): I will jump in here. I was going to ask about the whistle-blowing system. Obviously, we have read the report, but there is lots of stuff in it that we just do not have time to go into. I am particularly concerned, first of all, about the bullying of junior staff by more senior staff. That is appalling. Staff were maybe scared to raise a complaint, and they felt that, if they raised a complaint, it was slow to be investigated. I am interested to hear exactly how your whistle-blowing system works. I know that you started to detail it, but I am interested to hear about the number of whistle-blowing incidents and the range of issues involved. Does it have to be a more serious offence to qualify as whistle-blowing, or can it be a more moderate complaint?

Ms Edwards: With whistle-blowing, there are criteria that have to be met. We have a whistle-blowing manager who reports through the director of HR, and she will assess when anybody can make a complaint to her. For example, if there was fraud involved, it would be signposted to the finance department and then to the counter-fraud service in the Business Services Organisation. There may be a combination of issues, but they have to meet the criteria of being in the public interest or a safety issue. It can be a wide range of issues.

A lot of whistle-blowing tends to be about conduct or performance, and that goes through the bullying/harassment trail instead. Freedom to Speak Up seems to go further, from what I understand. We are only starting to look at that, and the trust board agreed last Thursday that we would certainly take some learning from that and replicate that as far as we can. We will tap into the Department of Health. Freedom to Speak Up has more independence and reports directly to the trust board rather than going through a director, which gives staff extra assurance and more safety. It seems to work well in the trusts in England, so we may be a pilot site for Northern Ireland. Certainly, if nothing else, we will take the positive aspects of that and try to replicate them in our trust.

The Chairperson (Mr McGuigan): When the story broke, I asked the Minister in the Assembly Chamber whether he would be prepared to engage with the trade unions. Is there regular engagement between the trade unions and trust leadership?

Ms Edwards: Yes. The trade unions were, for example, at all our town hall events. We meet trade union colleagues — the executive team — fortnightly, and we then have a wider meeting every two months, I think.

Mr Hagan: I meet the BMA through the local negotiating committee.

Ms Edwards: On the ground, directors, senior managers and their team have really good partnership working with our trade union colleagues.

Mr Mulgrew: As an example, Chair, we are in the process of recruiting a substantive chief executive, and, as part of that, I and another non-executive director and the HR director met people who have a vested interest. The trade unions were among those we met in order that they could tell us what issues, they feel, we face and what kind of person is required to solve those issues.

The Chairperson (Mr McGuigan): OK. I completely accept what you say about the anonymous nature of the letter. Unfortunately, since the story broke, I have had phone calls from people who are not anonymous. I am not saying that they are making exactly the same complaints, but they have detailed some of the issues. In the report, there are details of staff behaviour, and there is some criticism of trust governance. I cannot remember whether Diane asked and you confirmed, but I understand that you are submitting action plans to the Minister. When we last spoke, he said that he had not got the action plans. Sorry, it was in the Assembly that he said that. Does he have the action plan? I asked him whether he would make it available to us, and he said that he would.

Ms Edwards: We discussed the action plan at the trust board. The first draft of the action plan went to our trust board last Thursday, and then Tara, Chris and I met the PHA and SPPG on Monday and the department of the deputy Chief Medical Officer (CMO). They saw a draft version. We asked for their feedback and whether they had any other suggestions. We have been working on it all week, and, last night, it went to the PHA, SPPG and the Department.

The Chairperson (Mr McGuigan): We will see it when we see it. Can you tell us at this stage whether any of the actions cover governance in the trust and management?

Ms Edwards: Yes, we have themes. I do not know whether you want to pick this up, Tara. The themes include, obviously, the culture piece; we have a bit on trust governance and a bit on freedom to speak up, which comes within culture; and we have work streams that feed into the action plan. We are absolutely happy to send you a copy.

Tara, maybe you want to go into a bit more detail.

Ms Tara Clinton (Belfast Health and Social Care Trust): No problem. As Maureen said, in the action plan, we have a number of actions against the 15 recommendations. We have two distinct work streams. We are focusing on the culture, governance, communication and our workforce through that. We have the inclusion of staff side as well in the action plan. That has gone, as Maureen said, to the Department of Health, and we will continue to work on it. We have a weekly meeting; we have our terms of reference; and we will absolutely focus and work on that in collaboration with all.

Ms Edwards: Chris might want to speak about governance. We constantly review our governance arrangements. The review committee said that we are a supersized trust. We have an audit committee and an assurance committee, which is a prerequisite of every board. They suggested that that is probably too big; we are covering a full range of items from clinical issues to cybersecurity etc. They made some recommendations that we are already starting to look at. We may split that committee so that more time and focus is given to clinical issues, and that will help. The governance framework is continually evolving. We are tapping into the Department, which is doing some work on that, and we are trying to align with it. However, we are not going to wait. We are going to —.

The Chairperson (Mr McGuigan): I am sorry to interrupt. You talked about the clinical committee. One of the criticisms in the report is that:

Is that going to change?

Ms Edwards: Before the report completed, we had already had a trust board decision. A lot of papers, as you can imagine, go to the trust board. Each committee does a report to the trust board on any of its escalation items. We had made the decision at one trust board meeting that we would not necessarily need all the minutes behind that and that the escalation issues would be what was reported. At the next trust board meeting, even before the report came out, we decided that we would need all the minutes in case something was missed. Given that we have so much to cover in organisation governance, we tried to have papers with a sheet of escalation issues and then a sheet for each of the groups that feed into that but without the minutes. However, we had already decided that, for completeness, we would continue with the minutes.

Mr Mulgrew: To be fair, the criticisms in the report about governance were not unfair or unreasonable. They were reasonable criticisms, and we should take them on board.

The Chairperson (Mr McGuigan): I appreciate that.

We will meet departmental officials in the session that follows yours and hope to get some detail on what "level 5" means. Do you have any idea of what it means?

Ms Edwards: We received a letter last week, and we have the first meeting with the, I suppose, oversight group on the support and intervention on the level 5 next Friday. I understand that Tracey McCaig is coming in later, so she will be able to give you more detail on that. What it means for us — we absolutely expected it — is that more support will be given in an area where more support is welcome. There will also be extra intervention and more accountability until we can assure ourselves and others that we have this under control.

It is wider than cardiac surgery. We want to reassure ourselves. There is no evidence to suggest that this is widespread. We know that, in an organisation of this size and complexity, there are pockets of staff where there are tensions between teams and individuals; those concerns are raised, and we take them through processes. We do not believe that this is widespread. Others will come in to support and reassure us and will be reassured that it is no more than you would expect in a similar organisation.

Mr Donnelly: Thank you for your answers so far. This has been going on for a long time. I was shocked when I heard the initial reports of this. I could not believe it, but, when I started talking to people who work in the trust and in other trusts, I heard that this was well known about for many years. It is astounding to me that this had not come up before.

It is glaring from the report that people felt that they could not speak up. There was no point in speaking up. People were being bullied. Junior staff were being bullied: medics and nurses. It is a horrendous situation, but I was really shocked at the level of knowledge of this that people were contacting me about and at the length of time that they knew that it was going on. Colin said that it has been going on for maybe 10 years, but it has probably been longer than that. It has been very much embedded in the system. You are committed to getting to grips with it now, but it is shocking that that has been going on for so long and that so many people knew about it.

I want to focus my questions on two areas: first, the impact on your patients in particular. I asked the Health Minister about that a couple of weeks ago, and he told me that, off the top of his head, six patients had had their operations cancelled. He then changed that and said that, actually, they were postponed. Cardiac surgery had been postponed. That means that six patients who were due for surgery — very sick patients with high levels of risk of serious actions happening to them — had their operations postponed. Do you know who they are? Have they been contacted?

Mr Hagan: It is actually seven patients, and they have all had their surgery. That was all done within a couple of weeks.

Mr Donnelly: OK.

Ms Edwards: For some of them, it was within a couple of days.

Mr Hagan: They were all rescheduled promptly.

Mr Donnelly: Are they aware that their operations were postponed for behavioural reasons in the department?

Mr Hagan: One patient was prepped and ready to go to theatre, and the operation was cancelled at the last minute, which is a dreadful thing to happen to anybody.

Mr Donnelly: All had surgery within a few days. Did any of them come —?

Mr Hagan: All within a couple of weeks.

Mr Donnelly: A couple of weeks?

Mr Hagan: Yes. Tara and I talked about that earlier. They were all completed within a couple of weeks.

Mr Donnelly: Did any of them come to any harm in the interim?

Mr Hagan: One patient died in the post-operative period, but that was unrelated to a slight delay. There was a recognised post-operative complication. In any such post-operative complication, we always do an SAI review, so that is under review at the moment.

Ms Edwards: The family would be aware.

Mr Donnelly: A patient whose operation was postponed because of the behaviours in the cardiac unit — his operation was delayed —.

Mr Hagan: It was delayed by a couple of days. Unfortunately, the patient died of an unrelated complication in the post-operative period.

Mr Donnelly: OK. Obviously, these are serious issues with very sick patients. Families have been contacting me and are terrified about what this might mean for relatives who are waiting for cardiac surgery. The fear that you are putting into people who are already very unwell and very concerned about what might happen to them is real.

Ms Edwards: The effect on patients at a time like that is the most serious thing to come out of this. Tara and the team have been putting in additional support for patients as they come into our hospital and after recovery in order to make sure that they are reassured that there is a safe service and that everything is OK after their recovery. Over the past couple of weeks, we have put in additional efforts to make sure of that. We are very conscious of that because it adds to already heightened anxiety. I absolutely accept that.

Mr Donnelly: The other impact that I wanted to ask you about is the impact on the staff who had been bullied, particularly the junior staff. Did any of those staff leave the unit in the period when they were being bullied?

Mr Hagan: No. We have provided additional support to any staff who came forward. The bullying was predominantly among junior trainees, not senior trainees. We conducted listening exercises alongside the training agency and identified the individual who was responsible for that. That individual does not work with trainees — certainly not junior trainees — any more.

Mr Donnelly: It is shocking in itself that an individual cannot have access to a junior trainee in case they bully them.

Mr Hagan: I talked earlier about a similar issue that we had in 2020 with another surgeon who was also restricted from access to trainees. I am a surgeon: it is completely unacceptable.

Mr Donnelly: It is shocking to hear it described to you.

Mr Hagan: That is particularly so because your junior staff are the future consultants and specialty and specialist (SAS) grades who will work in that unit. It sets an awful tone in the unit, if trainees feel bullied or frightened to speak up. Having spent 20-odd years in surgical practice, I must say that it is not something that I have been familiar with in any unit that I have worked in, other than a brief time when I worked in Dublin. The impact of that on a trainee is profound. I was offered a job in Dublin, and I thought, "I do not want to work in this unit, because this is how they treat trainees".

It is utterly unacceptable that trainees and nurses would be bullied. I understand that surgery is high-risk, but people have to manage their emotions. I have spent half a lifetime in operating theatres, and I have seen excellent behaviours, particularly when things do not go well. That is when you need your team round you: you should not make them feel frightened. Bullying is completely unacceptable, and I will never defend people treating other people like that. It is just awful. I hope that we can give you encouragement in that we have recruited two young surgeons who are really excellent people. We have another excellent young surgeon who will, hopefully, start in the summer time. With time, hopefully, the culture in the unit will change. As I said to you when I made my short presentation, however, we still have more senior surgeons in the unit who are raising concerns against each other, despite everything that we have talked about.

Mr Donnelly: That is where I wanted to go. I wanted to talk about the potential damage to careers. You have highlighted an example where you did not take up a job because you felt that the behaviour in the unit was not right for you. Whom have we missed? We have missed people, and careers have been damaged here. I imagine that people have felt stressed and scared to come into work. It is horrendous to think of what that must have done to those people. What you said about the two new surgeons is great, but it has also been said — I think that it was said by Ciaran — that it takes five years to change a culture.

Mr Hagan: We linked in with another unit. I am not going to name it. The problem seems to be not infrequent in cardiac surgical units. There are several units in GB that have had similar issues, but they have seen poor patient outcomes associated with that. We have not seen that, but we know that the impact of incivility in teams eventually affects patient outcomes.

Despite all the issues, the team has managed to maintain excellent outcomes, as validated by NICOR, which oversees it. We look at surgeons' individual performance plots as well, and they are excellent. The patient experience in the unit is fantastic. It is consistently over 98%. We take regular feedback from patients about what they think. I am not trying to minimise the issues, but, despite all that, the outcomes and the patient experience are excellent. We have had patients coming forward saying, "Can we please say what it has been like?", as they have had a really good experience.

About 250 people work in the unit, and we are talking about the behaviour of a very small number of people. That is what finds us sitting in front of you today. More than 240 people want to come to work and do a really good job, and we need to support them and to recognise that.

Ms Edwards: This is probably a good opportunity to recognise the staff who come in every day, despite the behaviours that we have now become aware of. They have come in every day and worked together. There are teams in the wider unit who work really well together. ICU and cardiac surgery have really good relationships. In a lot of examples, in theatres, those nurses turned up and looked after one another. However, it is not acceptable. It is indefensible that they should have had to do that, and we will not tolerate that happening.

Mr Donnelly: I can only hope that it improves for them now.

The Minister has now confirmed that the trust is in the highest level of the support and intervention framework, which we are about to hear about. We finally got that confirmation from the Minister on Wednesday evening. How will we know that the actions that you have outlined here today — there are quite a few of them — are delivering positive change? How will we see the difference?

Mr Mulgrew: One of the first things to say about that is that one of the reasons why we gave everyone a copy of the report was so that those who work in the unit can see what the recommendations were, will understand that we have accepted all of them and will be able to judge us on whether we deliver on those things.

In the past, when there had been reports and recommendations, they were not shared as widely. That was one of the things that have come out in the report, as you will see. We decided that we will err on the side of transparency, so we are telling people what we will do, and we have asked them to hold us to account for it. I did that at all three of the town hall meetings that we had. We have undertaken to go back to people to give them an opportunity to tell us whether we are doing it or not.

Mr Donnelly: I expect that the Committee will take a close interest in those recommendations and how far they are being progressed. I imagine that we will be talking about this [Inaudible.]

Mr Mulgrew: You are welcome to come to some of those sessions to hear from the people themselves. We have no interest in hiding anything.

Mr Donnelly: I would be happy to do that, and I am sure that other members would be as well. Thank you for the invitation.

Ms Flynn: Thanks for your time at the Committee today. All these discussions are very negative, and I am conscious that, as we have all said, the public will be watching, particularly families and patients who are due to go into hospital for cardiac services or for other services. It is important that, out of all this, you maintain the trust of the patients who need the care and treatment.

One of my extremely close family members recently had surgery. It was not in the cardiac unit; it was in a different service. My mind is with all the life-saving work that is being done every day. That is to be commended.

Overall, the most important thing is that the service is safe, and you have made it clear that, throughout all the bullying and bad behaviour, patients have not been impacted on. It is really important that that message is put out there, because that is what I would want to hear if I were due to go in for cardiac surgery or any surgery in the Belfast Trust.

Chris, you mentioned all the steps that have been taken over the years to address the concerns and issues that the trust was facing. Maureen, you mentioned that the evidence suggested that it was all in hand and was being dealt with. However, you were not aware of how widespread it was. You are aware of that now with hindsight from the reports have been done.

Ciaran, you said that it is hard to talk about thousands of staff, but, as a leadership, can you confidently say that widespread bad behaviour such as that is not currently taking place elsewhere in your trust services? Maureen, you said that people will come in to, hopefully, help you to have that overview and really get into the detail, but have you done any auditing or checking across the service to be able to say, "Look, at this point, we are hopeful that serious issues like this aren't currently widespread in another part of our system"?

Ms Edwards: Obviously, there has been a focus on that from the staff in cardiac surgery during their daily huddles. As well as that, we had a nurse event in the past couple of weeks about speaking up. An all-user communication went out on Monday of this week to remind staff of the various ways in which they can speak up. All of our directors through the trust board and executive team have been going out to all their teams. Whilst some of the recommendations will be very specific to cardiac surgery, many of them are cross-cutting, certainly in the culture piece.

After the Peter McBride work, we set up a number of strands. We have "Chat with the Chief", but the big outcome of that was our open learning and just culture steering group, which feeds into the trust board. It is led by the director of social work, who, obviously, is steeped in that world, and HR. That work has been going on. We take feedback from that to get a bit of a temperature check on the organisation. However, we know that there is much more to do. We will use all the help and the things that we have already started to try to capture how staff are feeling. We have just closed this year's staff survey, so we will get a sense from staff of whether things are improving. You will know that, during COVID — this is not unique to the Belfast Trust or Northern Ireland — morale among staff was at its lowest. There were a number of years of industrial action etc after that. Our staff survey tries to take a sense check regularly. Those outcomes have been improving. We will continue to do that. That is from the Peter McBride work.

Mr Mulgrew: It is a good point, Órlaithí. I am a non-executive in the trust. When you are a non-executive in any organisation, the problem is that you do not know what you do not know. However, when you find out, you have a responsibility to do something about it. It is clear what happened, and we have a responsibility to fix it. We will live up to that responsibility.

Ms Edwards: It is really important to reassure not just those going in for cardiac surgery but, as you said, everybody going in for surgery. CHKS, which is the primary benchmarking company in England that looks at performance across trusts, did a piece of work a couple of years ago in the trust. In all but a few of our specialties, it reported that our performance was as good as if not better than the peer, by which I mean other teaching hospitals and centres of excellence. The few for which we were not above peer were usually because of a capacity issue. We have been working with others in that regard. Our cardiology, for example, is in the top percentile of the UK. Our renal transplant surgery is at the top of the European standard. Thank you for bringing that to people's attention. We have exemplary services. That is not limited to our acute hospitals. It is important to remind people of that to reassure them.

Ms Flynn: I used the example of my close family member, but, regardless of the type of surgery that you are about to go in for, if you hear that, it will spook you. If you are going onto an operating table, regardless of the reason or the service that is carrying it out, the news, the report and all of the talk will spook you.

Mr Hagan: We have excellent clinical outcomes in cardiac surgery, despite the problems. Cardiac surgery is heavily monitored, and the unit submits data through NICOR. We monitor the performance of individual surgeons through VLAD plots, so we can see their outcomes. If we see a plot start to drift, we will provide support to the individual surgeon to maintain their performance. As I said, two of our surgeons have been recognised as being in the top 5% of cardiac surgeons in the UK. Despite the issues in the team, it continues to deliver high-quality, safe care. This is also important: we have 50-plus clinical services in our organisation, and people come to work to do their absolute best. It is a massive organisation, and, with 23,000 people in it, we will have issues in some services. People are people, and they will sometimes not get along with one another; we need to be honest about that. It is about how we deal with that, being open about it and bringing issues to the fore. We have described how we have shared the report, warts and all, with all staff, so that they will understand that, because they came forward, we will take action.

Ms Flynn: Thank you, Chris.

My second question — my final question — is about staff feeling fearful or unsafe and afraid of reporting the problem: the bad behaviour, bullying or whatever the issue is. What is your assessment, as a leadership, of why staff would or could feel that way? Does it come down to individuals? Is it about the reporting process if something goes wrong? Is it about a lack of trust? For example, would someone think, "If I report something, will it be followed up, or will it come back on me?"? How do you get to the bottom of that? It is not good for anyone to feel that way. If you are going to implement the recommendations of the report on the cardiac service, the thing that you really need to get on top of is staff feeling fearful and afraid to speak up. If staff feel that way, there will always be another issue, another scandal and another service with the potential to go through this process. What is your assessment of that issue?

Ms Edwards: That is what our campaign on feeling safe to speak up and using the freedom to speak up — using what we are already doing — will be all about. What has led those staff to be fearful? I cannot say. The review did not say. I suspect that it could be a case of people thinking, "This could be somebody who will interview me for a job in future", "I am afraid of retribution", "I am afraid of a complaint being made against me", or, "I just want to stay under the radar". None of that will help the unit to move on, so we need people to feel safe. Whistle-blowing keeps it completely anonymous, and the report was anonymised, but, if that is not enough, we will need to do what it takes to make people feel safe. I suspect — it came through in the review — that some people think, "I complained before and nothing happened". Processes take a long time, and whistle-blowing, for example, does not involve going, 360-degree-review-style, back to the person who made the complaint, because that is not how the process works. We need to tease those things out. The nurses, in particular, at the town hall — go ahead, Tara.

Ms Clinton: At the town hall on the report, the nurses in particular spoke up and felt safe to speak up. The Nursing and Midwifery Council (NMC) event that has taken place since then involved nurses not just from the cardiac surgery unit but from other surgical disciplines across the trust. We spoke to the nurses and evaluated how that session went. They feel positive about speaking up. If staff want to speak up confidentially, they can do so, as Ciaran said, by using the QR code. We will be sense-making and checking as we go through the actions as well.

Ms Flynn: Thank you so much.

The Chairperson (Mr McGuigan): I am not discriminating against the two Alans, because they come last, but we have to be fair to our next witnesses, so I ask you to keep answers succinct.

Mr Chambers: I have a brief question, Chair. I will refer to the anonymous letter that we got. As my colleague Mrs Dodds said, when you get something like that, you cannot unread it, and you ignore it at your peril. By the same token, however, I am very uncomfortable with getting anonymous letters when people can use other means to communicate, such as talking to me anonymously or whatever and in confidence, so I am uncomfortable with that. I am conscious of what Ciaran said: it could be just one person sitting in their bedroom with a catalogue of grievances and typing out that letter, saying that it was from "Concerned Staff" — plural.

You indicated that you have regular dialogue with the unions every couple of weeks and maybe a more formal sitting once a month or every couple of months, and I am pleased to hear that. I would have thought that some of those "concerned staff" are members of a union. Do you identify anything in that letter that the unions have brought to your attention in those meetings? I would have thought that, if whoever wrote that letter was genuine and had real concerns, the union would be the vehicle to articulate them to you. Do you identify anything in it that the union has been bringing to you?

Ms Edwards: At our fortnightly meetings with the union, we discuss all the issues that are pertinent to the running of the trust. For example, after or even before health committee meetings, we discuss capital projects and what they mean for staff etc, so we raise those. They were mentioned in the letter. As for the other things, no. At every meeting with trade unions, we will always have conversations about staff's ability to speak up or any staff concerns, if there were groups that the unions think about. They would draw that to our attention. However, they would not have to wait until those formal meetings, because our HR colleagues and our service directors and their teams have really good partnership working relationships with the trade unions. I say that, but, obviously, there is always room for improvement. I am sure that trade union colleagues would like more from us, and, where these issues are concerned, we are happy to do that.

Mr Chambers: I am sure that a lot of what is in the letter has already been picked up by the report through the interviews that you did. I did not see an awful lot of new stuff in it that I was not already aware of by virtue of having got a copy of the report.

Mr Mulgrew: The reality is that, when you do not know who has written something, it is difficult. I got the letter only when I was eating my lunch. It felt as though it was based on personal gripes. It is likely that the individual is a constituent of some one of you, and, if they would come forward and speak to some of you on a confidential basis, you could bring the issues back to us. We have no interest in hiding from any of the issues, but parts of it felt like a personal gripe to me.

Ms Edwards: That said, the line in it that read:

suggests that, whether it is an individual, the message is, "We do not feel safe to say". Whether it is true, we know that that is an issue for us, and we will focus on that. The big questions coming from that letter for me are these: why did you feel the need to be anonymous? Why did you not feel that you could go through all the processes that you were talking about or a new and better process? That is what we will focus on from that letter.

Mr Hagan: I will go back to something that Diane brought up about managing the concerns about doctors. The change in and approach to that has been recognised by the two main doctors' trade unions, plus the GMC and Practitioner Performance Advice, in that there is a different ethos in how those things are applied. Issues such as this take time to be recognised across an organisation as large as ours. I thought that some of the things that came out in the report were historical issues that we had probably dealt with before. However, the letter that you referred to is upsetting. It is a shame that we cannot have a conversation with the person or that they did not feel that they could put their name to it or talk to somebody about it.

Mr Robinson: Folks, at the most recent session that we had with the Minister, I said that some of the behaviour here meant that it felt a bit like a Wild West bar. That was based on some of the information that we were getting at that time about the risk of violence in the unit and how the environment was not safe. There was also an allegation of implements being thrown. Following that, since we got a full copy of the report, it now feels to me that it is a bit more like the stuff of the playground. We, as a Committee, and you, as professional people, have more important things to be getting on with than discussing the behaviour — the patient behaviour — of people in that cardiac unit. I am sorry for being so blunt about it, but it is shocking that grown adults cannot behave themselves and that a costly report has to be done, Ministers have to be involved and motions are tabled in the Chamber, and here we are today having a session because of people who simply cannot behave. That is disgraceful.

Can I ask a question on the back of that? Give us a wee bit of a nugget here: are you confident that there will be harmony in that cardiac surgery unit? The report does not suggest that.

Ms Edwards: I can tell you that we have told staff and the trust board we will do everything that we can to make sure that we have a safe environment for people to work and train in. We will do our utmost. Behaviours will change, and people will, as they already do, feel freer to raise even small complaints about behaviours. That has happened. We will act on those complaints quickly. Whether tensions between individuals, including doctors, changes is, frankly, up to them. People have to take responsibility for their own actions, and, if they do not, we have to address that. Can I tell you that they will like each other and work well with each other? No, I cannot guarantee that. We will ensure that their behaviours are not impacting on other people in the unit and on the level of safety that, they feel, they have.

Mr Hagan: I have had some informal feedback from trainees who say that they have noticed a change. We have had a letter from a senior trainee saying that they enjoyed their time working in the unit. We have taken immediate action against an individual who was identified as bullying trainees, because it is completely unacceptable. In 2020, we took action against another individual. It is really encouraging that two new consultants have been appointed in the past few years, and we have a third consultant coming in the summer. We have other people who, I know, want to work in the unit, so those are really positive things through which we can reset the culture in that team.

I need to try to give you some reassurance that this situation does not reflect the culture in other teams in the organisation. Other teams in the organisation are upset, because they feel that they are being judged by the behaviour of a very small number of individuals. We have a giant organisation that we are all really proud to work for and lead, and this reflects the really poor actions of a very small number of people. I am glad that you have said what you said.

Mr Robinson: I have another point. I note that, in the report, there is commentary on having to wait eight weeks for some of the documents to be uploaded. Was there any reluctance on your part to do that? What was the delay?

Mr Hagan: There was an issue with the data-sharing agreement. The PHA commissioned it, not us. It was not that we were trying to hide anything.

Mr Robinson: OK. Are the designated clinical officers confident that they will get everything that they require, meaning that everything that they asked for they got?

Ms Edwards: Yes. Some of the feedback that we have had from our staff is that we could have given them more evidence on that. We probably could have got more, but there was a time constraint. For example, there was a recommendation that we go beyond the NICOR for some more personal data, and some of our staff were saying that we could have given them more. That is on us. There were issues with timescales and data sharing, and then there was time for redaction. There was nothing that, the review team felt, it needed to give it more assurance about the safety. There were a couple of things that we could have given the team to make that even stronger.

Mr Hagan: It gave us some recommendations on our assurance framework, which we are doing some work on as well. We have a big thing called the "assurance committee", which covers a lot of governance, and we will try to separate that so that we can focus more on clinical governance in the organisation. That is separate for social care. That was also one of the recommendations that came from the neurology inquiry. I met somebody from the Department today who has been working on the recommendations for that.

Ms Edwards: The key assurance for you is that there was absolutely no intention to hold anything back. Hopefully, the fact that we shared an unredacted report is testament to and a demonstration of our openness and transparency.

Mr Robinson: I had a couple of other questions, but I am conscious that we have run well over our time.

The Chairperson (Mr McGuigan): I will allow your colleague to come in for one very quick question and answer.

Mrs Dodds: Thank you, Chair. If raising the issues has meant that they are now being addressed and talked about, that is a good thing. Every day, I am humbled by and grateful for the work of our NHS staff, who do so much for us when we are at our sickest and most vulnerable. That is important.

I ask this again for complete clarity: if the Minister were sitting in front of me now and I were to ask him a question about issues in the Belfast Trust about the safety of patients, would there be something that he would want to tell me?

Mr Mulgrew: Certainly not that I am aware of, no.

Mrs Dodds: Thank you for that, and thank you for coming. I appreciate that. They are not easy issues.

Mr Hagan: That is not to say that there will not be something next week that we are not aware of.

Mrs Dodds: That is what happens.

Mr Hagan: I think that we have demonstrated our commitment to being open and transparent on the matter. I hope that you think that we have done that today.

The Chairperson (Mr McGuigan): Thank you all very much for coming. We appreciate it.