I work as an independent ethics consultant. Most of my work is concerned with healthcare ethics or policing ethics, and I have a particular interest in how trust is restored after things have gone wrong.

My Fellowship focused on how to make healthcare safer by responding to incidents of serious harm. For many years NHS organisations have been expected to carry out root cause analysis of harmful incidents. This was intended to reveal flaws in organisational systems, so that systems could be improved. Unfortunately, the way it has worked out in practice is that missteps by individual staff, rather than flaws in the systems they work in, have tended to be treated as the critical causal factors. I had heard of an approach being used in North America called the Human Factors Analysis and Classification System (HFACS), so I went to see how it was being used by health systems there.

Since my return I have adapted HFACS for use in the NHS and worked with several NHS organisations to help them adopt it. I have also supported others to carry out further research into HFACS. HFACS is not perfect, but it offers a practical way to investigate, learn about and improve system safety.