Who Controls the Past? Investigation, Patient Safety and the Power of the Pen

“Who controls the past controls the future: who controls the present controls the past.”George Orwell, Nineteen Eighty-Four

Nineteen Eighty-Four is a seminal piece of literature and one of my all-time favourites. (Animal Farm just pips it for me as my favourite Orwell work, but let's try to stay on track.)

Orwell's line describes how those in power can shape the accepted version of history and, through it, how people understand the present and imagine the future. I find that framing relevant to far too many organisational situations and scandals. The area it makes me think about most, though, is investigation.

Investigators Shape the Accepted Version of the Past

Investigators hold a huge amount of power, whether or not they realise it.

They hold the pen.

They decide which questions to ask, which evidence to pursue, whose experiences to seek, what context to include and how events are described. Humans love a good narrative; we are storytellers at heart. But that can be a problem. We can turn the messy reality of the past into a neat, digestible story and, in doing so, lose something important about what actually happened.

This is one reason why Human Factors and Safety-II thinking, particularly the work of Erik Hollnagel and others, is so valuable. Rather than focusing solely on failure, it encourages us to understand how work is actually undertaken within complex systems. It asks us to recognise the gap between work as imagined and work as done.

Healthcare investigations should seek to understand that gap. A policy describes how work is intended to happen. Real clinical environments involve competing priorities, operational pressures, resource constraints and constant adaptation. The investigator becomes the filter through which others understand that messy reality. The account they construct can either illuminate complexity or accidentally obscure it.

This principle sits comfortably alongside the aims of the Patient Safety Incident Response Framework (PSIRF). PSIRF moves healthcare organisations away from a narrow focus on blame, thresholds and isolated incidents, and towards proportionate responses that support learning, compassionate engagement and system improvement. At its best, a PSIRF approach encourages curiosity about how outcomes emerge within complex systems rather than a search for somebody to blame.

When Investigations Go Wrong

I'm going to deviate from my usual focus on patient safety investigations this week.

Recent coronial reporting has again drawn attention to how disciplinary and conduct processes can create serious risks when they are handled without sufficient care.

NB: A Prevention of Future Deaths report is not a finding of civil or criminal liability; it is issued where a coroner considers that action should be taken to address circumstances creating a risk of future deaths.

One recent report raised concerns about national guidance relating to the management of an employee who was the subject of a conduct issue. A second highlighted departures from policy and procedure, alongside concerns about the effective support and management of people who were the subject of concerns.

These reports brought the Horizon scandal straight back into my thoughts and the devastating impact it had on people's lives. Volume 1 of the Inquiry's final report records evidence relating to 59 people who contemplated suicide, including 10 who attempted it, and identifies a real possibility of a causal connection between the scandal and 13 deaths by suicide. Those findings alone paint a horrendously sad picture, even before we consider the impacts on families, friends, colleagues and communities.

Approximately 1,000 people were prosecuted during the period examined by the Inquiry. Many convictions were later quashed, some through the courts and many through legislation, after the reliability of Horizon evidence and the safety of those convictions came under sustained challenge.

Behind the headlines, however, sit imprisonment, bankruptcy, lost employment, lost homes, fractured families and damaged friendships. Lives irrevocably changed.

It would be too simple to attribute every consequence to one investigator or one investigation. The scandal instead demonstrates what can happen when flawed evidence, weak challenge, institutional assumptions and repeated investigative failures reinforce one another over time.

The Risks Hidden Within a Convincing Narrative

Investigations are often treated as an additional task for someone to complete on top of their normal day job.

If cases such as Horizon highlight anything, however, it is the power an investigation carries: the power to establish what happened and why, but also the power to cause harm when it is conducted poorly.

Confirmation bias is one risk. Others include:

• Cognitive tunnelling.

• Evidential overreliance.

• Failure to test competing hypotheses.

• Premature closure, where an investigator settles on a coherent explanation before the available evidence justifies it.

The challenge is that a narrative can be highly persuasive whilst still being incomplete.

Once we decide what the story is, there is a temptation to interpret subsequent evidence through that lens. This is particularly dangerous in healthcare investigations, workplace investigations and regulatory investigations where the consequences can affect careers, wellbeing, professional registration and public confidence.

The real question should not always be:

"Who made the mistake?"

It may be:

"What made it make sense at the time?"

Or:

"What does this outcome tell us about the system in which people were working?"

Those questions are often more difficult to answer, but they are usually more useful.

Investigators Help Shape the Future

The investigator therefore helps to shape the future.

The account they construct of the past influences what comes next. That may be punishment for the "bad employee". It may be redesigning systems to support success.

It may be identifying how workload, staffing, information, technology, environment and organisational processes interacted to produce an outcome. Or it may be no action whatsoever because the event is dismissed as a one-off that will never happen again.

This is why recommendations matter so much. A good investigation creates an opportunity to learn, redesign and improve. A poor one can reinforce the current position and encourage us to double down on our existing beliefs about how things should work, our work as imagined, if you will.

For healthcare organisations operating under PSIRF, this distinction is particularly important. Effective learning responses should generate insight that helps improve the conditions in which care is delivered. Recommendations should be traceable to the analysis, focused on meaningful system improvement and tested for effectiveness.

After all, completed actions are not the same thing as improved outcomes.

Investigators Also Shape the Present

The investigator also helps to control the present.

They influence how events are described, framed and communicated. Their language can create an anchoring effect. Once an explanation has taken hold, it becomes much harder to unpick, even when later evidence points elsewhere. I suspect most of us can think of examples where claims have been disproved, corrected or retracted and yet continue to influence public understanding years later. By shaping the present account, the investigator influences how others understand the past.

And the circle of control begins again.

This is one reason compassionate engagement is so important within modern patient safety investigation practice. Patients, families and staff are not simply sources of evidence. Their experiences can challenge assumptions, expose gaps between policy and practice and provide context that may otherwise be overlooked. More importantly, they are people affected by both the event and the investigative process itself.

Good investigation is not simply a technical exercise. It is a human one.

The Power of the Pen Requires Humility

The financial cost of Horizon gives only a partial sense of the damage. By August 2025, approximately £1.18 billion had been paid in financial redress to more than 8,600 claimants across the compensation schemes.

But money cannot bring back those who have died. It cannot restore lost years. It cannot repair every broken relationship or remove the trauma experienced by thousands of people.

As an investigator, you hold enormous influence. While you do not actually control the past, you literally shape the account of it that others come to accept. That account can influence decisions in the present and direct action in the future.

The responsibility is therefore not merely to tell a convincing story. It is to remain curious. To test the story against the evidence. To explore competing explanations. To understand work as done rather than simply compare reality against work as imagined. To preserve complexity where it matters.

And to ensure that the power of the pen is exercised with humility.

Because in healthcare investigations, workplace investigations and patient safety learning, getting it right should never be a matter of luck. It should be by design.

Read our guide to the Patient safety Incident Response Framework (PSIRF)