Introduction
In October last year, the Ethics and Integrity Commission replaced the Committee on Standards in Public Life as the body responsible for standards across UK public life. Doug Chalmers, who chaired the CSPL, now leads the Commission, and the new body has already begun to establish its priorities, launching reviews of lobbying regulation and the ombudsman landscape within its first months.
The Commission’s programme explicitly builds on CSPL’s prior work, including its vital Early Warning Signs report published last year. That report examined a number of high-profile public sector failures which resulted in public inquiries - from infected blood to Windrush, from maternity services to Horizon IT - finding concerning institutional patterns across sectors.
What the Committee found
The report lists nine recurring themes:
- Failure to listen to and act on concerns raised by employees and/or the public.
- Failure to investigate properly when things went wrong.
- Failure of the board to have proper oversight of issues and concerns.
- Overly defensive organisational culture.
- Failure to support a ‘speak up’ culture.
- Poor relationships within the organisation.
- Failure to understand the unintended consequences of policy decisions.
- Failure to learn from past mistakes, or similar incidents and failures.
- Failure to identify and share emerging themes that might have alerted the organisation to a developing risk.
To expand on a number of these points:
On the failure to investigate properly, the report identifies a pattern of organisations responding to serious incidents with reviews that were inadequate to the task. It quotes the Ockenden maternity review’s finding that "investigatory processes were not followed to a standard that would have been expected”. And that “The reviews were often cursory, not multidisciplinary and did not identify the underlying systemic failings”, while “some significant cases of concern were not investigated at all."
The report describes similar failures found in other major investigations, including the Infected Blood Inquiry’s finding that the NHS "did not respond to the infection of thousands of people with HIV and hepatitis… by undertaking investigations, providing detailed explanations, making sincere apologies and doing everything that could be done to learn lessons. Instead, what is apparent is a defensive closing of ranks."
On learning from failure, the report quotes the Windrush Lessons Learned Review’s finding that “A defensiveness borne of dealing with issues in the past, coupled with an inadequate comprehension of the potential scale and complexity of the problem, led to a lack of curiosity or willingness to learn or reflect.”
And it presents similar reflections from Infected Blood: “When it became apparent in the mid 1980s how many people had suffered serious illness as a result of their treatment with blood or blood products by the NHS, there was little apparent effort to establish precisely why that was, and to learn the lessons for the future.”
The report finds that these failures to learn were not simply administrative oversights and that they reflected something deeper about organisational culture. For example, it finds that "whether complaints are viewed as an opportunity or a threat is determined by the tone set by the leadership of an organisation. It requires leaders, at all levels, to value and prioritise the learning to be gained rather than resorting to blame, defensiveness and reputation management."
That observation connects many of the report's other themes: defensive cultures, failure to support speaking up, boards that were - as the Ockenden review put it - "reassured rather than assured" about the services they oversaw. Taken together, they describe organisations where issues are ignored rather than examined, where governance structures exist but are not used to hold leaders to account, and where warning signs go unheeded until they become crises.
These patterns are familiar across sectors. The triggers may differ but the underlying institutional challenges are common.
The role of independent investigations
Of course, things go wrong in organisations. A serious incident, a whistleblowing report, a regulatory finding, a pattern of complaints. But any one of them may be an early warning sign of a deeper problem. The question is what an organisation does when they arise.
Early Warning Signs suggests that too often, the answer is not enough. Organisations respond with internal reviews that lack independence, or treat individual incidents in isolation without asking whether they are part of a wider pattern. In some cases, serious concerns are not investigated at all. The decision to commission an independent investigation, and to do so early enough that it can inform the organisation's response rather than simply account for its failures, is itself one of the most important governance decisions an organisation can take.
But the decision to investigate is only the first step. An investigation scoped narrowly around a specific event will establish the facts of that event. It may well produce valuable recommendations. But if the underlying conditions that the CSPL describes are also present, a narrow investigation is unlikely to surface them. The organisation addresses the incident but not the reason it keeps happening.
The value of a well-scoped independent investigation is that it can do both. It can establish what happened in the specific case while also examining the wider context: whether this was a one-off or part of a pattern, whether the organisation's governance and culture contributed to the failure, and whether previous recommendations were implemented. Not every investigation needs to cover all of that. But the terms of reference should always be set with enough care to determine whether a broader examination is warranted.
Where it is, an investigation needs to produce not just findings but practical recommendations for change, addressing governance, accountability and culture, and not just operational processes. Establishing the facts quickly is important, but so is what an organisation does with them. The organisations that use investigations as tools for improvement are better placed to avoid becoming the next case study in a report like CSPL's.
The Public Office (Accountability) Bill (or “Hillsborough Law”) will, when enacted, make this point still sharper. The Bill imposes a statutory duty of candour on all public authorities and a range of private sector bodies at inquiries, inquests and other investigations, backed by criminal sanctions. Organisations in scope will be required to set out their stance on events in a “position statement” and to approach scrutiny with candour, transparency and frankness. Providing an accurate account requires properly understanding the facts. An independent investigation of the type discussed in this article may well be needed to do so. And a candid account which tells of unheeded early warning signs will be a difficult position to defend.
What this means in practice
For governance and legal leaders, there is a growing case for commissioning independent investigations proactively, with terms of reference set with enough care to examine culture and governance where warranted, not just operational process. Done well, they produce recommendations that drive real change and make the organisation stronger. They also mean that when scrutiny does come, whether from a coroner, a regulator, or an inquiry chair, the organisation is better placed to respond.
If you would like to discuss how independent investigations could support your organisation's preparedness, please contact Steffan Groch.
