UHB: When Organisational Culture Weakens the Control Environment

Case type: Governance, organisational culture and internal control
Organisation: University Hospitals Birmingham NHS Foundation Trust (UHB)
Jurisdiction: United Kingdom
Key review period: 2022–2023
Primary reviews: Patient Safety Review led by Professor Mike Bewick; Independent Organisational Culture Review conducted by thevaluecircle
FGL focus: Tone at the top, psychological safety, speaking-up arrangements and board risk intelligence

Case snapshot

Organisational culture is sometimes treated as separate from internal control. The UHB reviews demonstrate why that distinction can be misleading.

In 2023, independent reviews of University Hospitals Birmingham identified significant concerns involving leadership, staff experience, speaking-up arrangements and organisational culture. The central governance issue was not simply whether policies and reporting channels existed, but whether staff trusted those systems enough to use them.

Importantly, the Bewick Patient Safety Review concluded that UHB remained a safe place to receive care. It nevertheless warned that continuation of a culture adversely affecting staff morale, recruitment and retention could ultimately put patient care at risk.

What the official reviews found

1. Staff confidence in speaking up was weakened

The Bewick review heard from staff who believed that speaking up could result in no action or, in some cases, retribution. It also recorded concerns from some senior doctors that professional disciplinary procedures were inconsistent and that enforcement processes could be used coercively.

Those concerns require an important qualification.

After examining 17 GMC referral cases, the review said it found nothing exceptional about their numbers, types or eventual outcomes. Its concern was therefore not that every referral was improper, but that perceptions of inconsistent or coercive use of professional processes were contributing to fear among some staff.

The later culture review reinforced the wider speaking-up problem. Some staff did not regard the Freedom to Speak Up process as sufficiently safe or confidential, and concerns were reported about delays, escalation and feedback after issues had been raised.

2. Leadership style affected staff experience

The Bewick review recorded contrasting views of UHB's previous leadership. Some described it as decisive and effective; others experienced it as oppressive. Feedback from some dissatisfied staff described the emerging senior management style as “dictatorial and overzealous”, while other interviewees described it as robust but lacking kindness and empathy.

The review was therefore careful to recognise that the picture across UHB was complex and that high-performing areas also existed.

The later organisational culture review similarly concluded that leadership behaviour at board, divisional and local level materially influenced staff experience and morale.

3. Serious concerns existed around staff welfare and organisational response

The Bewick review considered the death of junior doctor Dr Vaishnavi Kumar and heard significant concerns from staff and her family about the organisation's response. Some responses were perceived by staff as lacking empathy.

The review also recorded an important limitation: the coroner had apportioned no blame to UHB for Dr Kumar's death. The governance lesson therefore concerns organisational response, staff support and tone at the top; it should not be interpreted as a finding that UHB caused her death.

FGL analysis: how the control environment can break down

The COSO concept of the control environment provides a useful lens through which to examine the UHB findings.

The mechanism is straightforward:

Leadership behaviour → staff confidence → willingness to report → quality of risk information → board oversight.

An organisation may have whistleblowing policies, incident reporting systems, risk registers and disciplinary procedures, yet still receive poor-quality risk intelligence if employees do not believe they can raise concerns safely.

A reporting channel is not an effective control merely because it exists. Its effectiveness depends on whether people trust it enough to use it.

Culture therefore influences the reliability of the information reaching management, internal audit and the board.

Remediation and organisational response

UHB accepted the recommendations arising from the reviews and began a wider programme of cultural and governance reform.

The Independent Organisational Culture Review proposed four fundamental shifts:

1. Greater openness and transparency.
2. Valuing staff and strengthening equity and inclusion.
3. Connecting organisational culture more directly to effective patient care.
4. Establishing a physically and psychologically safe working environment.

The review also called for changes to Freedom to Speak Up arrangements, leadership development, behavioural expectations and board oversight.

Subsequent status

The case did not end with the 2023 findings.

In August 2025, the Care Quality Commission rated UHB good for well-led, improving from its previous inadequate rating after what the regulator described as an extensive programme focused on culture, staff wellbeing, support and governance effectiveness.

The CQC found improvements in leadership, openness, governance and staff voice, although some staff survey indicators remained below peer-group averages and further improvement was still required in parts of the organisation.

This later development is important: governance failures should be studied together with the organisation's response and subsequent evidence of improvement.

FGL practical lesson

The UHB case illustrates why psychological safety should be treated as part of the control environment rather than solely as an HR issue.

Boards cannot assume that silence means that risks do not exist.

Where employees fear consequences, doubt confidentiality or believe that concerns will not be acted upon, formal escalation systems may provide false assurance.

The control question is therefore not only:

“Do we have a whistleblowing policy?”

It is also:

“Do employees trust the system enough to use it, and can the board demonstrate that concerns reach the right level and result in appropriate action?”

What audit, finance and governance teams should do

1. Test speaking-up arrangements in practice. Internal audit should examine staff awareness, confidence, confidentiality, response times and outcomes rather than merely confirming that a policy exists.
2. Analyse disciplinary and escalation patterns. Boards should monitor whether disciplinary, grievance and regulatory processes are being applied consistently and whether previous raising of concerns appears associated with subsequent treatment.
3. Protect investigation independence. Allegations involving senior management should have reporting and investigation arrangements sufficiently independent of the individuals or functions concerned.
4. Triangulate cultural indicators. Staff surveys, turnover, sickness absence, grievances, exit interviews, speaking-up data and employee-relations cases should be considered together rather than in isolation.
5. Monitor management's response to challenge. Audit committees and boards should consider how leaders react to internal audit findings, regulator criticism, adverse staff feedback and other uncomfortable information.

Questions for management and those charged with governance

• Can employees raise concerns about senior leaders without relying on those same reporting lines?
• How does the board independently assess whether staff trust speaking-up arrangements?
• Are disciplinary and regulatory referral processes periodically reviewed for consistency and fairness?
• Does the board receive cultural risk indicators alongside conventional financial and operational risk measures?
• When external reviewers or internal auditors raise uncomfortable findings, can management demonstrate challenge, learning and corrective action rather than defensiveness?

Primary sources

• Patient Safety Review into University Hospitals Birmingham, review led by Professor Mike Bewick, commissioned by NHS Birmingham and Solihull Integrated Care Board, published 28 March 2023.
• Independent Organisational Culture Review: University Hospitals Birmingham NHS Foundation Trust, thevaluecircle, published September 2023.
• Culture Review Report and Trust Response, University Hospitals Birmingham NHS Foundation Trust, September 2023.
• University Hospitals Birmingham NHS Foundation Trust — Well-led Assessment, Care Quality Commission, published 29 August 2025.

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Professional-use note: This FGL Case Brief is provided for professional educational and analytical purposes. It distinguishes, as far as practicable, between findings and evidence recorded in the official reviews and FGL's professional interpretation of their governance implications. It does not constitute legal, clinical, employment or audit advice.