Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Peter McBride and Dr Jennifer Hill who are external experts in the departmental intervention team. We have read your report. I invite you to make some opening remarks, after which we will go straight to questions from members.

Mr Peter McBride (Departmental Intervention Team): It may be helpful to briefly introduce ourselves. I spent most of my career in leadership in the voluntary and community sector. In the past six or seven years, I have worked across the public sector, particularly on culture, openness, a duty of candour and that sort of thing in health.

Dr Jennifer Hill (Departmental Intervention Team): I am from Belfast originally but have lived and worked in England and Scotland for an unspecified number of decades. [Laughter.]

I have worked for most of my clinical life as a consultant chest physician for over 20 years and latterly as the chief medical officer (CMO) of a similarly sized trust in Yorkshire until earlier this year.

Mr McBride: By way of introduction, we thought that we would talk you through a little bit of the process, which will not take very long. We will not go through the content of our report, on the assumption that you have read it. We will talk a bit about process and we will take questions on content.

This has been a challenging piece of work. We have heard lots of very difficult stories. At the start, our intention was to be as inclusive as possible. We created multiple ways in which Belfast Trust staff could engage with us. The first of those, back at the end of June and start of July 2025, was a survey that we put out to all staff. The Belfast Trust facilitated a video, and the survey came about on the back of that. We got 3,429 responses to the survey, which we were very happy with.

That survey allowed people to respond anonymously, which many of them did. It asked some high-level questions about their experiences of raising concerns, particularly whistle-blowing. It also afforded those who wanted the opportunity to take a step further to give us their email addresses so that we could follow up for more detailed information. Out of the 3,429 respondents, 710 indicated that they wanted a follow-up. We did those follow-ups and got more detailed information. There were some free text opportunities that allowed people to tell us their stories. Critically, the survey allowed people to say whether they wanted to engage with us face to face or in some other shape or form. Out of that 710, a further 138 indicated that they wanted to tell us their stories. We met those people over a period, through a variety of mechanisms, including face-to-face meetings and online group and individual meetings. We got a lot of data from that first group, which you can see in the report. We can talk about that during the course of this meeting.

The second category of people were those who contacted us off their own bat. Many of those people were prompted to do so by you. They contacted you and you directed them to us. We offered all those people the opportunity of individual contact. Again, we spent quite a lot of time speaking with them and listening to their stories.

The third category of people were those whom we sought out. Those are people who did not necessarily approach us but who were, for strategic reasons, of interest to us because of their particular area of work. Particularly in the case of medics, we sought those people out. I will ask Jennifer to expand a little bit on how we did that.

Dr Hill: There was clearly some overlap between our two sets of terms of reference. You will see what we were asked to look at in the report. I was asked to support the team in the response to the cardiac report in particular, but I was also asked to look at systems and processes that the board oversaw, including those relating to quality, governance and the medical leadership model. I spent a fair bit of time talking to the senior clinical and non-clinical leaders, the governance teams and a number of clinicians. I also visited some clinical areas and attended some governance meetings in order to get a hands-on understanding of how things worked. I also reviewed a number of policies and minutes of meetings in order to understand reporting in particular. I took a slightly different approach, but there was clearly an overlap between Peter's work and mine.

Mr McBride: In total, there were over 370 interactions. Most of those were with individuals, but some were with groups of people, as Jennifer described. We believe that everybody who wanted to speak to us about this got the chance to do so and to have input. In the report, we have earnestly tried to honour the stories that we heard. Some of them were difficult to hear. We have tried to be proportionate and balanced in what we have presented to you, but we have tried to honour the testimonies that we heard from the people who spoke to us.

We are happy to take any questions that you have.

The Chairperson (Mr McGuigan): Thank you very much, and thank you for the work that you have done on this.

The report was done on the back of another report, which identified poor behaviour and culture in the Belfast cardiac surgery unit. That was on the back of previous investigations and work, yet, in this most up-to-date report, you tell us that there is still significant risk associated with the dysfunctional team dynamics in the cardiac surgical team, despite all the time that has passed and the number of reports and the media attention that there has been. How concerned are you about the fact that it is still a problem, given all the investigations into that unit?

Dr Hill: I will say two things. We were asked clearly to comment on where we are now and what the team has been doing. You have raised the fact that we have mentioned ongoing risk. When I look at the situation, as an ex-CMO, I ask, "Would I feel content with a relative of mine going into that cardiac surgery unit this week to have an operation?" That is my test. The outcomes and the complications from that unit are good, meaning that the number of complications is low and the outcomes are good. I would be content for a relative of mine to go and have surgery in that unit.

We have identified that there is ongoing work for that team to do. Some of that has started: there is an external clinical director, and a load of other work has been outlined in the report. Risk is a dynamic thing. It is important that the organisation identifies the risk, and we have commented on that in the report, but it is then about what happens to that identification of risk. That is the important bit. We are recommending ongoing oversight, monitoring and reporting of the impact and efficacy of the interventions that the trust is making for the risk that we have identified. The identification of the risk is the important bit. What the trust does next, and the recommendations that we have made, are, I think, the things that will make a difference.

The Chairperson (Mr McGuigan): I am still a wee bit confused. I am obviously content, as, I think, everybody will be, that you are saying that there is no risk to patient safety.

Dr Hill: No, I am not saying that there is no risk. Every healthcare organisation has inherent risk, of course.

The Chairperson (Mr McGuigan): Sorry. Let me rephrase that. I was going on the phrase that I read in your report. It states:

I am a bit unclear about what that risk is and who is at risk.

Mr McBride: That is a really legitimate question. It is something that we have wrestled with. It is important to make a distinction between the risks that we are identifying and the risks that were previously identified by the DCO Partners report. That report identified issues with specific behaviours. The trust has worked, I think, very hard to challenge some of those behaviours, and it has put some measures in place. That is laudable; it is fine. However, we have found that, behind that, there are profound relationship issues in that team, which will not be fixed easily overnight or by sending people through some training.

When we talk about "ongoing risk", it is not that the risk has crystallised and that relationships have now broken down, everybody is fighting with each other and patients are suffering. Rather, it is that, as we look forward, if the trust does not deal robustly with the situation, that will inevitably have an impact on patient care and the quality and stability of service that is provided. When we look at a risk, we think, "What are the things that might impact on this in the future? What are the things that could go badly wrong?". This is one of those things. That is why we are pleased that the trust has done what it has done to bring in an external clinical director on the ground. He is an eminent cardiac surgeon, and he comes from outside this jurisdiction, so he has a clean set of hands, if you like. He is coming in with a very clear mandate to analyse and understand the dynamics of what is going on but also to bring a fresh set of eyes to this. The risk is that that breakdown of relationships will have an impact on care. At the minute, we do not believe that it is doing so, but, if that risk is not dealt with, it will, ultimately, crystallise. That is what we are saying.

The Chairperson (Mr McGuigan): That was my question. Ministers, civil servants, permanent secretaries and trust chief executives have been aware of the ongoing situation for a long time, yet, even after this report, you are saying that somebody external is coming in. I am a member of the public and also the Chair of the Health Committee. I am concerned that, despite all that, we have not solved those relationship problems in the Belfast cardiac unit.

Mr McBride: When you read our report, you will see that we are saying that. Let me put it like this: the Belfast Trust is a large, complex organisation and there will always be behaviours in it that are challenging. The same is true in any trust. In the past, we have been critical of the way that the trust has, or has not, dealt with those issues. That is a very clear criticism in what we are saying. We believe that things have changed positively in the recent past. In the past year, there have been seeds of hope. We mention legacy issues in the report. These problems go back a long time, and with a new chief executive — I know that Jennifer Welsh is sitting behind me — and a fresh wind, there is a possibility of change. Committee, we will be very clear with you: this will not happen quickly or easily, because, frankly, staff are cynical and do not have, and have not had, a lot of faith in the system. They are now starting to get a glimmer of hope, but that needs to crystallise over time. I do not think that what you are saying is wrong, Chair, but this is a complicated issue, and it will take time to resolve it.

The Chairperson (Mr McGuigan): Obviously, your work was initiated because of the problems in the cardiac surgery unit, but you were asked to look beyond that across the trust. When I was reading the report, it almost looked to me as though you are not saying that there are not issues: you are identifying issues, but you are trying hard not to identify them to us and maybe the public. Maybe there is a good reason behind that.

Mr McBride: There is.

The Chairperson (Mr McGuigan): However, we would like a wee bit more detail about the cultural behaviour issues beyond the cardiac unit. How serious are they? What are the risks involved? What is being done to address those issues?

Mr McBride: We have wrestled with this and have taken an intentional position. We have heard stories and testimonies from staff about other very concerning behaviours, and in each of those cases — there are a number of examples around the trust — it is very difficult for us to judge whether that is unusual for the Belfast Trust, compared, for example, with other trusts, because we do not have that data and, therefore, it would be unfair of us to pick on that as a specific issue. We sought significant assurance that — I promise you that we did this really robustly — the trust was aware of the other areas that we were concerned about and had interventions already in place to address them.

When we made the decision not to name the issues, it was partly because we did not quite know where to draw the line — you know, what would get in and what the threshold would be — and it felt unfair to the trust and to the public to raise concerns that were not necessarily fully able to be crystallised. We sought assurance from the trust about the interventions that it is making and, as you will see in the recommendations, sought very clear assurance that there was visibility in the trust about those areas. You may want to speak to colleagues in the next evidence session about that, but, from our point of view, we felt that our job was to reassure ourselves that those issues are under control.

Dr Hill: I reiterate what Peter said. In any large organisation like the Belfast Trust, there will be teams that have difficult interpersonal relationships. It is about how the trust manages and deals with that and supports staff. Our recommendations are trying to ask this: if teams are dysfunctional and individuals behave less well then expected, are the managers and teams equipped to understand processes and do they have the skill set to nip those issues in the bud before they become a major problem?

As I said, we sense-checked with the leadership team that it was aware of all the areas for which we had heard repeated narratives, and it was. Therefore, we did not think that it was constructive to start picking out areas.

The Chairperson (Mr McGuigan): In your report, you helpfully give a lot of data on procedures, processes, investigations, inquiries etc. However, I could not find any detail or numbers for the people who may or may not have been disciplined. I accept that your report also states that in the cardiac unit there is a dispute about the veracity of the previous report. We have spent a long time dealing with this because there are cultural and behavioural issues. You now say that they are not just within the cardiac unit but beyond it. I would imagine that in any organisation where there is bullying, bad behaviour and a toxic atmosphere, there will be an HR process that leads to people being disciplined. Are there any examples of people being disciplined in the Belfast Trust for bad behaviour?

Mr McBride: That is another excellent question. Let me unpick some of the challenges behind that. We sought data on that, and we wanted to find a way of benchmarking data from the Belfast Trust with that from, for example, other trusts. There is some of that in the report, but we ended up discovering that, in an organisation like the Belfast Trust, if people have no faith or very little faith about raising concerns, the levels of raising concerns become low. That is part of the paradox. People do not do it because they do not believe that it is going to have an outcome. Therefore, getting overly fixated on what the data is telling us will give a skewed picture. That is the rabbit hole that we found ourselves going down. Therefore, we tried to focus on finding the narrative that allowed us to explain the disparity between what we were seeing — the Belfast Trust being largely in line with, and in some cases better than, other trusts when it comes to the numbers of grievances raised, whistle-blowing and that sort of thing — and what we were hearing, which is that there is very little trust in these processes and people do not necessarily believe that they are going to be listened to, treated properly or have their complaints acted upon. The conclusion that we came to is the one that I just described to you: where there are low levels of trust, people just say, "What is the point? There is no point in me raising that. They are not going to do anything anyway".

Legacy will be one of the biggest challenges faced by the new leadership. I am sure that you have seen Jennifer Welsh's video: as CEO, she has set a superb tone for the start of her career and for the response to this. The key bit is saying to staff, "We recognise that harm has been caused, that you have been hurt and that we have not done things well in the past. We are going to fix that, but it is going to take time". A process is required. Facetiously, I say that it is a little bit like Northern Ireland in general: we have to deal with the past as well as engage with the future. It is exactly the same for the Belfast Trust: there is remedial, restorative work that is required alongside the transformation work to deal with the pain that has been caused.

The Chairperson (Mr McGuigan): OK. The issue of confidence in the whistle-blowing process and the process by which staff can come forward shone through in the report. The level of staff confidence in those processes was pretty shocking. I am not going to deal with that issue: I am pretty sure that other members will probe you on it.

The size of the Belfast Trust as an organisation, and the challenge that that presents, is mentioned in the report, and other officials have previously commented on that issue at the Committee. This is a question that I will ask in the next session, but I will also put it to you: given the size of the Belfast Trust, do you both believe that it remains manageable when it comes to issues of poor staff behaviour, governance, procedure and good human resources practices?

Dr Hill: I worked in an organisation of a not dissimilar size. It is about how the organisation is run, how the leaders are trained and the culture of the place. The question that I think you are getting at is whether it too big and therefore unmanageable. I do not believe that it is. There are many other organisations outside health that are considerably bigger and can manage those things, so I do not think that size is the issue. It is about governance, processes and culture.

Mr McBride: I agree with Jennifer on that. The Belfast Trust has not realised that, as an organisation with over 20,000 people, how it manages its staff needs to be a priority. In one way, scale is irrelevant if you have the right infrastructure to deal with it. The complexities in the Belfast Trust are less about its size and more about the scope of what it tries to do, because it has general hospitals and regional centres of excellence. How that is managed and organised is challenging. When it comes to the simple issue of scale, lots of large organisations are managed really effectively, and there is no reason why the Belfast Trust cannot be one of those.

The Chairperson (Mr McGuigan): You have made a good few recommendations on that issue. My final question is about your recommendations. You have handed the report to the Minister. Everybody is aware of the report, and it is now public. What happens to your recommendations? Can the Belfast Trust pick and choose, or does it have to implement every recommendation?

Mr McBride: It is over to the Belfast Trust now. In a way, it is not for us to answer that. We made our recommendations because we want the Belfast Trust to do them. We did not make them gratuitously. We have thought very carefully about them. To be honest, I would be really disappointed if the Belfast Trust did not implement them.

There is something in this about understanding that it is a long game. It will not be fixed easily or quickly. When we talk about culture change, we are talking about years. Again, I go back to the issue of winning hearts and minds. There is a really important process here, which is about getting staff confidence back and getting them to feel that they are being well led and managed, that they are safe to raise concerns and that the organisation is genuinely interested. I have been quoted extensively, from the work that I have done on the Being Open framework, as saying that it is "immoral" for an organisation to ask people to speak up if it is not prepared to listen. The Belfast Trust has been in that position for a while, and that really needs to change.

The Chairperson (Mr McGuigan): Have you been or will you be tasked by the Minister with doing any follow-up work on the recommendations?

Mr McBride: There has been a suggestion that we are part of the decision process that might happen at some point to de-escalate the organisation from level 5 of the intervention framework. We are both very open to having a conversation on that. That would be a sensible thing to do. We have invested heavily in this. We are both passionate about the possibility of change. If we were invited to be part of that, we would both be very pleased to be involved.

The Chairperson (Mr McGuigan): I probably should have said this at the beginning, but, before I hand over to members, I make the point that your report is clear that the trust is a big organisation with over 20,000 staff. What we are talking about is not necessarily representative of the experiences of those 20,000 staff. The important issues of poor culture and behaviour need to be addressed, but the experiences of work and patient outcomes are positive for a lot of people who work in the Belfast Trust.

Mr McBride: That is a really important point to emphasise, but I would not be overly dismissive of the numbers. It is not like a general survey. When we sent out the original survey, we specifically asked people who had experience of raising concerns to respond. That is why we say in the report that the people with whom we spoke are "experts by experience" on what it is like to raise concerns in the Belfast Trust. Arguably, they could be 100% of the people who have tried to raise concerns. That is why I think that the data is valid for what it is. It was not a representative survey of the whole trust. It focused on the experiences of the people who have tried to raise concerns. That is what we have tried in the report to communicate to you with, I hope, integrity and vigour.

Dr Hill: It was also really noticeable that, even as people told us unfortunate stories about how they felt that they were treated when they raised concerns, equally they said that they wanted it to be better and to be part of that. It feels like that is a group that has been hurt, so to speak, but is keen to be part of the solution, which feels like a very positive position to be in —

Mr McBride: It is a very committed group.

Dr Hill: — albeit it is sad that they went through that.

Mrs Dodds: I echo that point, because it is important to say that, every day, we are thankful for those staff who turn up, save lives and look after us when we are at our most vulnerable. It is really important to say that.

I thank you for the report. It certainly is extensive. Some things in it are very concerning. The Chair has dealt with your view of the potential risk in the cardiac surgery unit, so I am not going to focus on that. I am going to focus on culture and, perhaps, managerial issues versus the board, and how things may or may not have fallen by the wayside.

The report states:

That is damning.

Mr McBride: That is the truth. That is what we heard. It was very difficult to listen to that and try to make sense of those experiences.

Mrs Dodds: I have read the report through two or three times to get a handle on all its themes because there is a mine of information in it. Having said that, what I do not find in the report is a sense of accountability and responsibility for the toxic environment that you describe. Your report refers to:

— and —

You do not, however, address the issue of accountability and responsibility for that. There is an appetite to move forward, but we cannot move forward until we address the issue of accountability. To be honest, Peter, I find that in a range of issues to do with health. We run away from accountability.

Mr McBride: It was difficult, so let me be clear about how we understood the situation. We talked to a select number of people, so the people who talked to us had those experiences. There were 17,000 people who did not talk to us. I do not know whether we can argue that those 17,000 people did not have those experiences. I do not know. I am not sure that we can go that far. We were resistant to drawing generalised conclusions about a whole culture from the specific examples that people gave us. We felt confident about saying, "These experiences were very real. They exist in this organisation, and we assume that they exist in most organisations". We were prepared to say that the organisation was failing culturally in its response to those behaviours. All of you will have had experience of large organisations. There is bullying in large organisations. Those behaviours exist: unfortunately, that is human nature. I am not sure that we were in a position to say that they exist any more or less in the Belfast Trust than anywhere else. We were prepared to say, however, that, from our experience, the Belfast Trust had failed to respond to instances of such behaviours as adequately as we would have hoped that it would.

I hope that you can hear the nuance in what I am saying and what we are wrestling with. There are lots of people in the Belfast Trust who have not experienced bullying or any such behaviours. We focused on the intelligence that we got from the people who were at the pointy end of things, their experiences and how the trust responded. In many of those cases, the trust responded poorly, and that needs to improve.

Mrs Dodds: Who is responsible? You describe an organisation that is bloated managerially. There is little accountability from managers: nobody knows who is doing what. Who is responsible? Who is responsible for the damning situation that you describe in your report? Unless we address those responsibilities and accountabilities, we will not know how to move forward.

Mr McBride: There is a constructive way of talking about this, which is about accountability, responsibility and moving forward. From a corporate point of view, the organisation is responsible. It is true that the board is responsible for the activities in the organisation. You, as an accountability Committee, can expect a very robust response from the Belfast Trust on what it is going to do about the matter. The question of who is to blame is different and much more problematic. It is a systemic, cultural problem that is very hard to pin down to a single thing, a single set of people or a single level of management. In one way, it is quite pernicious and difficult because of that.

It is very hard to allocate individual responsibility. If I were in your shoes, I would want to hear that the organisation was accepting responsibility for the problem — not denying it — and moving forward with a robust plan to deal with it. That is the bit that I think is most challenging.

Mrs Dodds: I will move on to the issues that you talk about in the report. You have cordoned off some issues as being legacy issues, which, in my view, and, I think, in your view, is a polite way of saying that they are very difficult and you do not know how to deal with them. I have spoken to a large range of people, mainly consultants. Those are eminent people in Northern Ireland, and they describe, as you did, a punitive culture. They describe the impact that it has had on their families and on their mental well-being. They feel that they have been punished for raising concerns and that, because of that, they have been thrown into the maintaining high professional standards (MHPS) process. Those people are at a fairly low ebb and deserve more from the report and from the trust than for their issues to be lumped in with legacy issues.

On the legacy issues and maintaining high professional standards, conclusion 13 of the previous report states:

Was that your experience?

Dr Hill: To go back to your legacy point, we were very clearly told about the past and how the past was the weaponisation of MHPS, but, equally, a large number of the clinicians, consultants, clinical directors and chairs with whom we spoke said that there was definitely a narrative around the "punitive" approach being replaced by a "supportive" one. The number of people involved in MHPS processes is referenced in the report and is incredibly low.

I agree with your point about legacy. I am not sure that it is about the issue being too difficult to deal with. As Peter said, the hurt that individuals feel about the past has to be acknowledged, but there was clearly a narrative from many consultants that that was not how they now perceived the approach from the medical director's team and things had changed.

Mrs Dodds: For some consultants, things are irreparable. It is too late —.

Dr Hill: That is exactly the point.

Mrs Dodds: They are irreparable. I have spoken to people who have left the Belfast Trust. I have spoken to people who no longer practice in Northern Ireland because of the situation in the Belfast Trust.

It took me quite a while to process some of the information. It is appalling. It is not legacy, because page 13 of your report shows that there has been a steady increase in legal claims against the trust over the past year because of those issues. I will ask Jennifer Welsh about who is paying and where the money is coming from, but the trust is continuing to pay and to fight legal cases and employment tribunals on that very point. The problem cannot be cordoned off; it has to be dealt with.

Mr McBride: I promise you that, in talking about it as a legacy issue, there is no implication that it will be cordoned it off. We have spoken to many of the people to whom you have spoken. I spoke to a number of retired consultants in particular who told me exactly what they told you and whose lives have been deeply damaged by their experience. We are very cognisant of that.

There is a change in direction from the trust, but, as with other points, that will take time. We describe it as legacy because there is the sense that it is not the same now as it was then and that it will take some time to work through what the repercussions of the past will be. The issues around litigation etc are to do with the time that it takes to work through some of the consequences of issues that happened last year, the year before, or two or three years ago. Those things take a disproportionate amount of time to work through. One of the big criticisms around MHPS was about the length of time that the investigations took.

I do not disagree with you at all: the problem is vexatious and difficult. There is certainly no intention on our part to suggest that it should be packed away and forgotten about. It needs attention. Specific attention needs to be given to how you deal with it, in order to free up the organisation to move forward. That was the intention of calling it legacy.

Mrs Dodds: There is a big piece of work missing from the report to tell us in clear terms exactly what happened, why it happened, and why MHPS was used in that way. The first report that we received says that. Why was MHPS used in that way? Why are some clinicians hurt beyond repair? It is a fact that they are. I was disappointed, Peter, that the report did not address that fundamental issue, which will not go away and will continue to cost the trust financially. There is no accountability in the report when it comes to that issue.

I will ask one last question, and it is about structure. The report describes a managerial system that seems to be a little bit chaotic, with very little cognisance of who does what, and so on. In that situation, it is easy for stuff to get lost. Everybody who knows me knows that I am not a big process person, but process is important when you are managing an organisation of 22,000 people. You have reported that almost a fifth of that organisation told you that they have no confidence in management. That is lethal stuff.

I have spent a long time looking at how on earth management accepted the handover of a maternity hospital that has cost £100 million or thereabouts that cannot be opened because it is unsafe. Is it possible that, in the kind of chaos that you describe between management and boards structures, those kinds of things can get lost in the telling?

Dr Hill: There was probably more of an emphasis on that in my work. I do not think that I would describe it as chaos. I reflect on why some recommendations were made about the board, particularly its committees and structure. Many large teaching hospitals and institutions around the country have had a load of stuff to deal with in the past five years. The Belfast Trust has had to deal with a pandemic, massive waiting lists, a change in senior staff and significant inquiries. It has had a lot of things to deal with, day to day. I worked in an organisation in which, after a visit by our regulator and a very significant inspection, we had to look very hard at our committee structure and spend some time with the board looking at how things are reported. We were not in chaos, but some work was needed.

I would not describe the situation in the Belfast Trust as chaos. The wealth of governance and quality data that the organisation produces could be more streamlined to make it easier for the board to sort the wheat from the chaff and have the data analysed in a way that makes it easier to see the key priorities. There are ways in which the situation could be significantly improved, but I would not describe it as chaos.

Mrs Dodds: I will leave that point because you and I will disagree on it. It is overly burdened with managerial process — there are words to that effect in your report — without people being clear about who does what.

Every now and then, I look up the papers of the trust's board. The most recent papers on the website are from a long time ago, and they are incomprehensible. How on earth are board members, who receive a huge amount of information, meant to assimilate and work with that?

Dr Hill: There are recommendations in the report about precisely that.

Mr McBride: We recognise that.

Mrs Dodds: I suspect that asking people to deal with that stuff is how we got into the position that we have arrived at on many things. Thank you very much.

The Chairperson (Mr McGuigan): The report says that, as of October 2025, the latest available papers were from January of that year. That is quite a gap.

Mrs Dodds: Yes. January 2025.

The Chairperson (Mr McGuigan): That is a bad gap.

Mrs Dodds: For my sins, I look them up every now and then to see whether anything has changed.

Mr McBride: If you have also read this report twice, you must be —.

Mrs Dillon: Apologies that I had to step out. I checked, and you did not answer this question while I was out. I want to understand how we are going to ensure that the outcomes from the recommendations are measured. You said that the trust will decide whether to accept the recommendations. We will have the new chief executive in front of us, and I imagine that she will be asked whether she will accept the recommendations. I am on the Policing Board, and, when there are recommendations for the PSNI in a report, we bring it in front of the board or one of the board's committees and ask, "Which recommendations are you accepting? If you are not accepting recommendations, why? How do you plan to implement the recommendations that you accept?". We measure that implementation, and PSNI has to report to us regularly. Is there a mechanism for doing that in this case, or is that still to be established depending on whether the trust accepts the recommendations?

Mr McBride: My understanding is that the trust is accepting of the recommendations, but, again, I do not want to speak for the trust; I am sure that Jennifer Welsh will speak clearly for her part. It is wholly reasonable to expect that, at some point, the trust will present a detailed plan of how it expects to implement the report's recommendations. That is certainly what I would expect and what would be normal. I have been involved with the hyponatraemia and neurology inquiries. When recommendations are made, a response plan is normally put in place. It would be reasonable for the Committee to expect to have sight of that to reassure you that the exercise is not a token one and that there is some detail behind what the outcomes look like. We have recommended a five-year people plan, and I would very much like to see how that process will take place and what measurables will be in it. Staff engagement should be intrinsic to that process. Staff should have a sense of ownership and be able to participate in shaping the metrics for success.

Mrs Dillon: Measurable outcomes are the most important thing in what we do, because it is about the future.

I will go into the past a wee bit now, but it is about the future. Peter, we discussed candour with you at a previous meeting. One of the big issues in this case was the inability to be candid. I do not know why staff were not candid about what was happening, why they did not feel as though they had somewhere to go to say what was happening or why, if they did, people at the next level were not candid about what they were being told. Why did we not know more about this sooner? If there had been candour, we would, could or should have. Do we not now need to ensure that there is a duty of candour?

I accept what you have said about risk, and the Minister has said that there was no risk to patient safety. You have said that while there is risk, it is no greater than the risk in any other cardiac unit. I accept that, but I am still nervous for the families who have people whom they love going into the unit, and I am worried about the staff. How do we improve that situation and ensure that candour is at the heart of every one of our units in every part of the trust?

Mr McBride: I share your concern. It is reasonable to be a bit nervous. Further reassurance is required, and there is a process that will take time and energy. This is not a binary matter; it is not that the situation was terrible but is now fine, so we cannot all take our eyes off the ball and feel completely happy. There is a need for concern, scrutiny and ongoing questioning because the situation will not be easily or quickly resolved. The issue of candour is really important, and I agree with you. My understanding of the direction of travel is that Northern Ireland will get a statutory duty of candour in the near future. I have maintained all along that bringing in a statute will not make a difference; it is about the culture.

I will describe some of the stories that we heard that might explain the situation that you described. If you are in an organisation, have been bullied by your manager and want to raise a concern, but the person with whom you are meant to raise it is best mates with your manager, you may feel that you cannot raise it with them. You may try to raise the matter with the person above, but they might ignore you or tell you not to worry because it is just banter. We heard that story multiple times, and it creates a culture in which people have no trust or faith in raising concerns. That is why you had not heard about it.

There is an interesting consequence of the cardiac surgery report. People spoke to us and we asked them, "Why have you come forward now?", and they said, "We saw what happened with cardiac surgery, but this is the first time we have seen someone raising a concern and action being taken. We thought that we could speak now". I was quite shocked when I heard that because it shows the depth of cynicism about coming forward that there has in the organisation until now.

Jennifer and I both feel, because of the timing, that we are on the cusp of change. Attention is needed, including time, support and resources. The situation will not be fixed quickly, because cultural change must be nurtured. You had not heard about it, because it had not filtered up or been a priority. There was no formal people report to the board of the Belfast Trust, so there was no mechanism by which anyone could ask the question. The situation now is fundamentally different, and those metrics will become a source of significant interest to the board because of what has happened, which is a hopeful sign.

Mrs Dillon: I agree that there needs to be cultural change, and the two things go side by side — one cannot go without the other. It goes back to the first point: we need to see measurable outcomes. That will be about doing something similar to what you did with the staff and getting an update on how things have changed on the ground.

Ms Flynn: Thank you very much, Peter and Jennifer. Peter, I go back to Diane's point about the accountability and responsibility following on from the report. You have been involved in that type of work for a long time, but was there a report or presentation to the Department of Health around two years ago on similar issues?

Mr McBride: You are talking about the work that I did.

Ms Flynn: Yes.

Mr McBride: I am happy to talk about that. A few years ago, I was commissioned by the Department of Health to do a piece of work on being open. It was the start of a process to develop a framework, which, as you may have seen, has been out for consultation and is about to be finalised. At that time, the Belfast Trust approached me and offered to be the first trust to engage with the concept of being open. Its then chief executive had just come out of the neurology inquiry, and, to be fair them, they recognised that they had an issue and wanted my involvement. Remember that the focus of that work was on being open; it was not an analysis of the Belfast Trust and what was going on there. The purpose of that work was to get the intelligence that I needed to develop the Being Open framework.

That involved a process that was not dissimilar to this one. I talked to a lot of staff and, while doing so, heard similar things to what I have heard in this process. That left me with a problem, because I could not hear that stuff and not do something with it. To be fair to the trust, and to the then chief executive and then chair of the board, I told them what I was hearing, and they said that I should present that as part of the story to the board, which I did. I delivered a presentation on two occasions, but the content was not as comprehensive as it has been in this report. Instead, my remarks were quite focused on the senior team, challenges with the way in which it was behaving and how the individuals in it were behaving with each other.

That was not a formal report; it was a presentation to the board. I was very conscious that I had not been commissioned to write a report, and I did not want to step beyond my mandate, which came from the Department rather than from the Belfast Trust. My mandate from the Department was not to write a report on the Belfast Trust or its senior leadership team. I hope that you can hear, from what I am saying, that I was slightly stuck between a rock and a hard place. For my own integrity, I fed back to the trust what I had heard and my view on that. It was up to the trust to respond to that, in whatever way it chose.

Ms Flynn: OK. I have been reading through the report that you have just published, and I am trying to get a sense of whether, going back two-plus years, there was any formal ministerial response or direction or any formal procedure or response by the senior trust management or the board on some of the issues, which, obviously, have come up again two years later?

Mr McBride: I think that it was dealt with as a concern by the Belfast Trust. It did not escalate beyond the Belfast Trust. Again, it was not my job to report that back through the departmental system. It was for the trust to deal with that. It is my understanding that some action was taken and some further work was done. I was not privy to that. I offered my views on it, and then I had nothing more to do with it.

Ms Flynn: The Minister was aware of it.

Mr McBride: The Minister was not aware of it.

Ms Flynn: OK. Going back to Linda's point, it is about how we, as a scrutiny Committee, can support the Department of Health to support the trust on next steps, accountability, outcomes and all the rest, because that, first and foremost, is where we all want to get to for our health and social care staff.

I will move on to the issue of HR, because significant challenges were flagged in your report about the HR function in the trust. There were, I think, 19 references to that in the report. Jennifer, you mentioned the size and the complexity of the organisation that you are dealing with. Peter, you also said, correctly, that, regrettably, you have to expect instances of bullying and bad behaviour in any organisation that is so vast in size. On the issue of the HR function in the trust, do you have any assessment of why the quality was failing with regard to complaints being processed in the proper way? There has been some changeover in staff in the trust's HR department and maybe even a reduction in its size. Is the HR service failing the trust?

Mr McBride: In most of the organisations that I have worked in, people have complained about the HR department. They tend to want the HR department to do more than what is appropriate for it to do. I want to acknowledge that. My expectation of the HR department in the Belfast Trust is the same as it is of the HR department in any organisation: it is the custodian of the processes that we have described, including those for raising concerns, whistle-blowing and supporting staff to speak up.

Managers have a responsibility to action those processes, but, in the organisation, HR is the custodian of them and should protect people's rights as employees. It should not matter whether they are porters or paediatricians: HR's job is to make sure that all staff have the same fundamental rights as employees and to action that. That is the starting point.

I am not sure that the Belfast Trust — I am talking about the corporate body — knew how to use HR. I am not blaming HR individuals in this at all. The organisation itself had not prioritised people and therefore had not prioritised or supported its HR function to deliver on that. That is just my view. There is probably an issue around resourcing for a large organisation. There is possibly a question about the number of staff who are required, but there is also something about where that sits in the organisation's priorities. It was my experience a few years ago, and is my experience again now, that HR has not had the central priority that, in my view, it should have for an organisation that has 20,000 staff who are, arguably, its key resource to deliver services. Our recommendation is to bring that front and centre. Make your people your priority. They deliver your services. Support them, manage them, challenge them when they behave badly, protect them to raise concerns, but make them your priority and build your strategy around that. That is what will shift this.

Ms Flynn: Thank you very much. We can pick that up with Jennifer Welsh in the next session.

Peter, you said earlier that, if the issues that were raised with you and that are described in the report are not dealt with robustly by the trust, it will have an impact. You then talked about how long it might take to fix some the issues and said that it is a long game and could take years, so we are talking about a protracted process. What would be your message, after all your and Jennifer's work on the report, when you say that there might be an impact if this is not robustly dealt with? Maybe you want to pass a wee comment to expand on that.

Mr McBride: There are two things. First, I acknowledge that people were courageous in coming forward to speak to us. One of the responsibilities that Jennifer and I felt with this was how to honour the courage that they had had. These were people who were sticking at it, as Jennifer said. They continue to love the Belfast Trust, love the work that they do and are proud of the work that they do and the outcomes that they deliver, as well as having had those terrible experiences. If nothing is done about this, the first impact will be that those people are let down. They will have had the courage to speak up, but nothing will happen. I would certainly feel that acutely. Having heard what I have heard, I feel a responsibility to make something different.

What the trust needs to do now has already started. Jennifer Welsh's video response to the report is pitch-perfect in its message to staff, which says, "We acknowledge that harm has been caused. We are looking forward, we are going to work hard to fix this, and we are going to involve you in that". Understanding that this is going take time, what people need at the start of this is hope. They need to believe that somebody will listen to them and take the matter seriously and that there will be a difference. At this point, the trust has a responsibility to signal the way forward and say, "We are taking this seriously. Here is the direction of travel. Here is where we are going". Both of us have received feedback in the past day or so from people whom we spoke to, and "hope" is the word that they have started to use. They have said, "This gives us some hope that there is now a way forward". That has to be a good thing.

Miss McAllister: I am sorry that I cannot be there in person. Thank you for your comments so far. I have a number of questions. I will go back to the recommendations. I think that all of us on the Committee agree that there is an issue not just in the Belfast Trust but in a number of trusts with how whistle-blowing is moved forward.

In 2018, after the hyponatraemia inquiry, Justice O'Hara made 96 recommendations, one of which was to have online mechanisms for whistle-blowing. In its response to the Committee today, the Department said that it considers the recommendations relating to that to be implemented. This report has come out in 2025, seven years after the recommendations from the hyponatraemia inquiry, and it is quite clear that it is quite simply not working. Forgive me if I am sceptical as to whether I believe that it will change now. There are too many other examples where staff feel that they cannot speak up. Those who do have counter-claims made against them. What kind of assurances, from both of your perspectives, can be given that the work that you have undertaken will result in changes happening?

Mr McBride: I am not sure that we can give an assurance. Our job has been to diagnose and give a direction. The assurance that you are looking for needs to come from the people following us and from the Department. I will speak specifically about whistle-blowing. The problem with whistle-blowing in the Belfast Trust is that there is a huge amount of confusion about it. Having lost confidence in any other process to raise a concern, people thought that their last resort was to be able to use whistle-blowing. At times, it was used inappropriately, and people became frustrated and disappointed because it did not, for example, protect their anonymity, which they expected it to do. There were alternatives that they could have used, but some people did not necessarily know about them, including prescribed organisations such as the ombudsman or the Regulation and Quality Improvement Authority that they could have whistle-blown to. That was not widely known, however, so there was a lack of awareness of what their options were. The reason that we have recommended an independent regional whistle-blowing facility is not to undermine the necessity of the trust to get its act together on its own whistle-blowing capacity, but because there is such a degree of cynicism and lack of trust in the trust around this that there is a need, even in a temporary way, for there to be a visible and independent regional capacity for that.

It is exactly the same around the regional freedom to speak up; it is the same principle. Arguably, that is what any good trust or manager should be doing on a daily basis. That is not where we are at the moment. There is no trust and there is very little confidence in the system. Therefore, we need something in the interim, and perhaps in the long term, that allows people confidence that, if they raise concerns, there is a place that they can go to in extremis. That is why we did that, Nuala. I cannot give you assurance, as I sit here, that that is going to be done. That can only come from the Department and the trust itself.

Miss McAllister: We will certainly ask about that later. It is disheartening when you see that inquiries made recommendations years ago and the Department says that those things have been done when, actually, the same issues arise. You talked about legacy issues, but it is still really important, for the sake of transparency and accountability, to ask questions about that.

There was roughly an 18-month period between when some complaints were first made until, I believe, maybe October to December 2023 or 2024, when it seemed that relations, indeed the whole atmosphere, was different in the cardiac unit. Then it seems to have gone down or been frayed again. You said that you cannot really quantify it exactly, and we all understand that, but do you think that, because of the way that relationships are at the moment, there is a risk of even more people leaving? Do you think that the unit can continue the way that it is, or are personnel changes needed?

Dr Hill: We spent a fair bit of time meeting each of the surgeons and the rest of the team. Any team disquiet or disharmony will always lead a clinician to consider whether there is a team elsewhere that would be a happier place to work. That is always a risk if you have a team that is not happily working together. However, bringing in an external clinical director — as Peter said, a highly respected cardiac surgeon whom the trust knows of — shows the seriousness with which the trust views the service and how important it considers it to be. In fact, we met cardiac surgeons with the chair and the interim chief executive and expressed that exact point. From that, my sense is that they know that the service is valued and that they are cared about as a team. That, plus the surround work that is being done, is the best that the trust can do. There is a risk that individuals could move on, but I think that the trust has to invest the time and energy in trying to keep that team together so that we have a service for the future for Northern Ireland.

Miss McAllister: What happens, then, if we have people who are not the lead or not the consultant surgeons but who are training and who, hopefully, can step into the shoes of those who decide to retire or move on? This is a regional service. What happens if even a small number of individuals who are being trained for the future leave, either to the Republic or across the water?

Dr Hill: Nuala, it is very hard to answer the question about what you do if you are short of personnel. There are only 300 cardiac surgeons in the UK. There are not a lot of them. It is a pretty small specialty, but it is a highly regarded unit. I am very hopeful about future recruitment, but, yes, it is a risk, and that is exactly why time and energy is being spent on trying to improve that team dynamic.

Miss McAllister: I want to ask about maintaining high professional standards. Some of that is mentioned in the report, but it is not very detailed. Are you able to elaborate on how many complaints or counter-complaints were made regarding maintaining high professional standards? My understanding is that a large volume of complaints were counter-complaints. Are you aware of whether many, or any, of those have been dismissed?

Dr Hill: No, I do not know the details of individual cases. In the report, we provided you with the details of the ongoing cases, and, as we said in the report, a number of years ago, there were a very large number of open files that were concerns about doctors, rather than necessarily about MHPS. We do not have the level of granular detail that you are asking for.

Miss McAllister: OK. It strikes me that something that should have been looked into is the level of power that people have to use the current process to silence. That is very important, because, if we do not look into those issues and change all of them, others might also do the same in the future. Do you think that the trust board and management will be looking into that? I will ask the representatives in the next evidence session about that, but can you understand where I am coming from? There are concerns that we are not looking at the tools that people have to make counter-claims in order to absolve themselves of responsibility.

Mr McBride: We have been very aware of that dynamic, and that was the big criticism. The word that was thrown around about MHPS historically was that it was "weaponised". That is what people were talking about: if you raise a concern about me, I will raise a counter one about you. Jennifer and I are quite reassured that that culture — that single component of that culture — is no longer happening. That is based on the testimony of a number of the senior consultants to whom we have spoken. That is not to dismiss Diane's point, which is that there is a very significant lack of trust because of the way that this was handled before, but there has been lots of evidence in the past year, empirical as well as anecdotal, that shows that there has been a shift in how that process is being used. It is a very important question to keep asking, because the way that you are describing it is exactly the way that the harm was being done. It was felt to be an abuse of power or a misuse of power. That is a very important question to keep asking.

Miss McAllister: I have more questions about the whistle-blowing process. During the process that you had with all the individuals involved, were you aware or concerned that managers, regardless of what structure they sit under — clinical, HR etc — were under scrutiny and that that then played a role in the actual whistle-blowing investigations? What arises time and again following inquiries that we have, whether about Dr Watt or hyponatraemia, is that some of the people who we expect to implement change are the very people who were involved at management level in the issues in the first instance. Are we seeing that in this case?

Mr McBride: Yes, I think that we are, and that is what some people told us. They said that their experience of whistle-blowing was that they would raise a concern and the very people who were dealing with the concern were the ones whom they had the concerns about. In that regard, I will use the word "chaotic". There has been a chaotic feeling around whistle-blowing, and how it has been understood and managed. That is not just the responsibility of those who have "whistle-blowing" in their title. That is about how ordinary managers manage it. I think that you are right, Nuala, and that is one of the reasons why, alongside the trust itself paying attention and improving its internal communications and clarity on how it manages whistle-blowing, there is a need for people to have reassurance that, if they do not trust that and are not satisfied with that, there are other remedies that they can take so that they do not feel trapped or powerless. If they are not satisfied with or do not feel confident about using mechanisms that the trust has, they need to know that there are other credible mechanisms that they can use that will support them to do it.

Miss McAllister: individuals involved. One thing that is missing from the report — Diane mentioned this — is that accountability of the individuals involved. Surely, if you do not have that, how can people have confidence that any system is going to bring about change? People will just continue to get away with it, issue after issue. We see it all the time. We see it not just in health, but we see it in health a lot more. If we do not have individual accountability as well as organisational accountability, what is going to change? Who, ultimately, is held accountable, and how many? I am not asking you to name people, but I believe that Ciaran Mulgrew was a sacrificial lamb when it came to this issue. Reading the report, I do not understand why he is the person who has been held responsible when there are people who have had their hands all over this — and it happens time and again. What is it going to take for something to change?

The Chairperson (Mr McGuigan): I do not know whether you want to comment on that.

Mr McBride: Our hope is that the report will precipitate change. That is why we committed to do it and why we wrote it. We certainly believe that if the actions that we recommend in the report are taken, it will make a difference. However, there is a big "if" in there. It requires the trust and the Department to take responsibility and to move forward with it. That is our aspiration.

Miss McAllister: Thank you. I have more questions for the trust later, but it is disappointing that we do not get to ask questions of people who were involved, even higher up the chain of command, during that six- or seven-year period.

Mr Robinson: Thanks, Peter and Jennifer. Peter, you referred to the number of staff who came forward, some on the back of communications that they had with us, and whom we subsequently encouraged to —

Mr McBride: Speak to us.

Mr Robinson: — speak to yourselves. Obviously you spoke to a broad spectrum of people who made comments about a broad spectrum of people. Without detailing roles, how far up the health service chain did those allegations go? I ask because one communication that I received from a surgeon alleged that a very senior individual in the health service was "nasty" and "a bully". Was it your experience from those whom you spoke to that it did not just go across but also went up?

Mr McBride: Yes, it is fair to say that we heard a very broad cross-section of criticisms that went up and across the organisation, right to the top and across. Given the number of people whom we spoke to — I can tell you that, at times, it was very frustrating, because we had to be clear to people that we could not follow up on individual cases: it was not our job to follow through, despite our sometimes hearing things that were very distressing — we did hear a cross-section of criticisms that went up and across the organisation.

Mr Robinson: I had no communication with Diane prior to this, but she used the exact term that I had written down: "damning". That refers to pages 15, 16 and 17, which covered the feedback from staff. I will quote some of it:

A total of 65% said no.

A total of 61% said no. Worse still:

Almost 80% said no. The reasons were "fear of retaliation" and a "belief that nothing will change". That is just stunning. It goes on again, worse still, when it talks about the main themes or the nature of the concerns that they raised, one of which is patient and staff safety risks being ignored. We still have a health service that speaks frequently about the importance of good mental health, but here we have, by way of the consequences that they felt from those concerns that were raised, "mental health harm" and "suicidal thoughts". What are your thoughts on that?

Mr McBride: That reflects the moral trauma that people experience. It also reflects what we have said a couple of times: in the Belfast Trust, you have staff who are deeply committed to what they do. They care deeply about their patients, and it is their life vocation to do that work. There is a mixture of challenge with that because of the very clear pressures that the health service is under. That is not particular to the Belfast Trust, but reflects the challenges that the health service faces, I would argue. We have used the word "impossible" in here, and we stand over that. Sometimes we ask staff to do impossible things, yet they turn up every day, they do it, they give of their time, and sometimes they give of their health to do that because they are so committed.

The evidence speaks for itself. Do remember that this is 17% of that population, so there are other people in the trust who have not had those experiences, but we were targeting those with specific experiences of trying to raise concerns. Maybe it is stupid of me to say this, but this is really important. The reason we have done it and the reason that we have communicated it to you in the way that we have is that we believe that it is really important. It is people's well-being, and, ultimately, there is a very clear link between the well-being of our staff and patient safety and the quality of outcomes. As an organisation, the Belfast Trust is a people organisation. It is people who deliver care; it is people who look after us when we need them; and it is the trust's responsibility to look after those people.

Mr Robinson: A lot of the recommendations on the back pages here use the word "should". In our belief here, we would like to have seen "must". Even in recommendation 7, you say:

"Consider"? What if they do not? What if they consider it and say, "We have considered it and we believe, bloated organisation that we are, that we will remain as is"? What is the fall back on that?

Mr McBride: I suggest that you speak to those who are coming in after this session, because there is a bit in this where we say, "Here is what we find and here is what we believe you need to do". Arguably, the experts in the matter are sitting behind us. They are the ones who will say how best the recommendations can be implemented.

Indeed, I am sure that you will hold them to account for how they choose to do that.

We in this room are all grown-ups; we all have responsibilities. We have done our bit. Now the trusts need to step in and work out what it will look like in practice, and your job, among others, will be to hold them to account. If, with all the different roles represented in the room, we are all agreed that our joint purpose is to improve the health service and the care to the level that the people of Northern Ireland deserve, we each need to work out how we will step in to take that responsibility. That is the big challenge that we all face.

Dr Hill: You are absolutely right. Where we have said "should consider" in our report, it means that there needs to be some nuance and that it is not quite so clear cut. In some of the recommendations, we have been a bit stronger in our wording because we both felt more strongly about them. It would be for trust to say, "The recommendation says we 'should', so there needs to be a jolly good reason why we wouldn't", and they would have to explain that reason very clearly. We have been as strong as we thought was appropriate in our wording of individual recommendations.

Mr Donnelly: One of the great things about going last is that all the questions that you were going to ask have already been picked up by almost everybody else. The report comes out of a very concerning, long period of bad and unacceptable behaviour. When this came to light, there were huge concerns in the Committee about what had been going on. Your investigation was instigated in order to take a deeper dive into that.

I have a couple of questions. I will go back to one of the first things. The report states:

in the cardiac unit. What are the risks to patients and to service delivery?

Dr Hill: We tried to explain the individual patient risk earlier but possibly did not do so as well as we might have done. As I said, if my relative were going into that unit, I would feel safe and comfortable. However, we know that psychological safety in the workplace is required to have a highly functioning team. Teams in which individuals trust each other and have each other's backs and want to innovate and develop, will do that best if they have psychological safety. To maximise that team, it is important to pay attention to that. There is a risk in the cardiac unit because we know that there has been dysfunction in the team. We want it to be a highly functioning team, developing and progressing. That is what needs to improve for that to happen. That is how I would describe it.

Mr Donnelly: It remains dysfunctional, then.

Dr Hill: There are ongoing relationship difficulties between members of that team, but the interventions that are under way aim to improve the situation. Our recommendation is clear: the chief executive and interim clinical director would keep a close eye on that team, going forward.

Mr Donnelly: I think that seven patients had their operations postponed because of those behaviours. Is that still a risk? Is there a risk, if there is continued dysfunction in the team, that more patients will have operations postponed?

Dr Hill: There has been absolutely no suggestion, while we have been doing the work, of there being any issues in that regard.

Mr Donnelly: OK. Your report mentions that some cardiac surgeons questioned the validity of the original report. It seems that there is an attitude of, "This is not needed. We're OK and we're going to continue in this vein". I know that you have put a quite a bit of extra governance around that team. There is a cardiac consultant, who has been in post for six months, and there will be regular checks at three months and six months. Given the prevailing attitude that the investigations are not warranted, can you be confident that change will happen?

Dr Hill: I will explain a little more. I think that some of the surgeons did not recognise the toxic culture that was described in that report because they have not witnessed it in their practice. It is more that the way in which the unit was described externally felt unfair from their perspective. They were concerned about the impact of the description on the wider team. From their experience of their theatre, on their ward rounds and in their clinics, they did not see the behaviour that was described. It was more a case of that than of them saying, "We don't have a problem". They had not personally experienced it, and they saw that the nursing staff and others felt quite hurt by the way in which the culture had been described. That is more what they were getting at.

Mr Donnelly: Some of the patterns in the original report were about bullying, particularly the bullying of junior nurses, many of whom are female and from overseas. During your investigation, did you pick up any sort of trends about the bullying of females, particularly young females, or overseas workers?

Dr Hill: No, but do you want to extrapolate, Peter?

Mr McBride: I spoke with a couple of people not from Northern Ireland for whom coming from overseas was an added dimension to their anxiety about raising concerns. People from overseas with, perhaps, visa restrictions had an added anxiety that, if they were to raise concerns about what they saw, it would affect their employment or their ability to stay here. That was a very particular challenge that had not necessarily crystallised; it was just an anxiety that they carried with them. I do not think that that is news. We understand that one of the difficulties for people from overseas is being able to feel that they can challenge. It is one of the cultural challenges that we face. I am fairly confident that the trust does some work to support staff who come from overseas when it comes to those cultural differences and the expectation to raise challenges here. I am quite confident that that is understood and known, but it is an important issue, Danny.

Mr Donnelly: The trust remains in a level 5 intervention. You mentioned earlier that you have been approached about being involved, at some point, in some other event in which you review how recommendations have been taken forward. Do you have any view on how long that level of intervention should remain in place, when it should be reduced, or what the threshold for reducing it should be?

Mr McBride: I do not have any specifics. I assume that what is required is a convincing response to, for example, the fact that everyone needs to be satisfied that there has been a robust and credible response, which gives staff hope and gives the Department confidence that those issues are now under control. I have no sense at all of the timing of that.

Mr Donnelly: One of the figures that really struck me in your report was the 62% of people who reported seeing behaviours that should have been reported but did not report them. Only 20% did. That is very concerning.

Mr McBride: That is the link with patient safety. Part of what we did, having had the data, was to speak to people about why they would not raise a concern. They said things such as, "There's no point", "Nothing will be done" and, "I'll get punished if I do". Those things are all connected.

Dr Hill: The proof of the pudding will be in the eating. It will be when people start to raise concerns, and something is done, and then the story is shared. It will be when there is a culture shift, and people will be able to say, "Look, the stories need to be told about how raising concerns was welcomed and actions were taken on the back of that". That is the message that needs to keep going out. I am sure that it is something that the trust is thinking about.

Mr Donnelly: We have talked about the metrics of outcomes. Will that continue to be measured? Should we continue to look at whether people, as you said, feel that they are listened to and that their concerns are taken on board?

Mr McBride: A lot of thought needs to go into that. In a weird way, if an organisation is showing low levels of people raising concerns, that is not necessarily a good thing. That may be counterintuitive; you may think, "We want to drive that down", whereas we are saying, "What we'd love to see in the Belfast Trust is that level of concern raising going up". However, it would be awful if that were to happen, and it then came to you for scrutiny, and you were to challenge it on that. There is a sophisticated conversation that needs to be had about what success will look like. It has to go beyond simple metrics. There has to be an understanding of the stories. Jennifer has just described it: what are the stories behind it? What are the examples that people can give? They give us examples at the minute that are very negative, such as, "My friend raised a concern, and she ended up having to leave". You have all heard those stories as well. What needs to happen over time is that alternative stories about good experiences start to come in. There needs to be a sophisticated interpretation of the metrics, where we see an increase in people raising concerns as a positive thing, especially if those are being positively resolved. The questions that we ask will determine the answers that we get. It is important to ask the right questions to make sure that we get the right answers.

Mr Donnelly: No problem, thank you. I know this report is just the start of change, and I hope that the recommendations will be accepted and that this Committee can scrutinise how those recommendations are implemented and ensure that the change is measured. It will be over to the trust now to do that and to rebuild trust with staff and the public at large.

I have one last question. This started because of an incident in the Belfast Trust. I have heard from people in other trusts who have concerns about that type of behaviour in their trusts. I absolutely encourage them to blow the whistle on that, raise concerns and make sure that they do not walk away and that concerns are always raised and addressed in the appropriate manner. Do you think there is another Belfast Trust or another cardiac unit out there?

Mr McBride: It is an impossible question. If I could answer it slightly differently — I am not a politician, but I will try to not to answer the question that you are asking

— I think that there are lessons in this for the region. I do not quite know the mechanism by which those lessons would be learned. The Belfast Trust is not alone in the challenges that it faces. It is unfair to focus too much on it when some of the issues are clearly across the whole region. There is an opportunity here for some learning across the region. We made a couple of departmental recommendations on the premise that those would have a regional impact. If some thought were put into what the regional learning might be, that would be very useful. I hope that that is an answer.

Mr Chambers: I have a very brief question. I think that, particularly among the public and maybe even in this room, there is, perhaps, a misunderstanding of what your terms of reference actually were and a higher expectation of what your report would say. Just to clarify, you were sent in to identify the problems, but it was not your brief to fix them. You have suggested cures, but it will be for others to take up the baton, going forward. It is important to clarify that for the public.

You talked about the fact that it will be a long-term fix, and we know that there is no magic wand. People are not going to start liking each other overnight. It is a long-term project. This might be a difficult question to answer, but if the Health Minister brings you back in a year's time and says, "You have the same terms of reference, go in and have a look", what would you expect to find? What would you see as success? What achievements following on from your report would you see as successes?

Dr Hill: There are some obvious ones around committee structure and reporting outcomes and reporting people metrics, which are measurable process things. The culture bit is the bit that is going to take longer. To expect a change in that in a year is probably a tall order, but I guess we would want to see more flowers blooming around the place in the stories that we hear and people saying, "I can see more hope and more evidence". There was an example in a trust that I worked in previously, where a medical student pointed out to a brain surgeon that he was about to do the wrong thing. The chief executive found the medical student, thanked him, and said that it was fantastic to have the courage to speak up. That is the kind of story that you want to be told. It is a rather extreme example. Seeing shoots of hope alongside those rather procedural process things is what I would say.

Mr McBride: In a year's time, I would love to meet people in the trust — ordinary members of staff — who would say, "Over the past year, I have been actively involved in helping the trust devise its people strategy, and I have had a real influence in how that is influencing my bit of this organisation. I can show you how that is going to improve my well-being". I would love that sense of the Belfast Trust, as a community, taking ownership of that and staff being facilitated to have their voice heard and being given agency to change things themselves, as well as the trust doing what it needs to do. It is about mobilising the talent that exists in the organisation at a grassroots level to help people take responsibility and ownership.

Alan, after a year, some things will be very doable. It is not going to be fixed in a year, but, after a year, I would expect certain things to be in place, and we should see the green shoots of hope for the staff. As we chat to people in the café or wherever, they might tell us stories like the one that Jennifer mentioned and say, "We had a problem, we raised it, our manager took us seriously, we made changes, we have learned from that and now we are moving on".

Mr Chambers: Thank you very much for your work. Obviously, a lot of time and effort went into the report.

The Chairperson (Mr McGuigan): Diane, can you ask a quick question for a quick answer?

Mrs Dodds: First, I agree with you about the priority that should be given to HR. In defence, you indicated that the whistle-blowing manager operated on their own without any administration, and that is an impossible task in a trust of 22,000 people. You mentioned the issues that Alan Robinson raised, and you described them in some detail. You gave the metrics about how the trust responded to people and the lack of confidence. You described it as "an abuse of power". Was it maladministration?

Dr Hill: It is hard to define the cause; some of it was probably competence, confidence, ability and desire. It is hard to diagnose the cause.

Mr McBride: A lot of what we heard was, anecdotally, about people who had raised concerns and managers not knowing what to do or actively doing the wrong thing. The proper processes were not followed, but there was no discipline around them, and the fact that they were not followed was not picked up. It became a vicious circle, and I do not know whether you could call that maladministration. It was about a culture with no discipline around following the proper process.

Mrs Dodds: We are back to my first point about the lack of accountability and responsibility. We will not have fixed that until somebody is accountable. We are going around in circles.

The Chairperson (Mr McGuigan): Thank you very much for the report and for giving your time today to answer our questions. I appreciate that. Thank you very much.

Mr McBride: Thank you for the opportunity. We appreciate it.