Chapter 16
The Board
The emergency session of Meridian Health Group’s board was held at nine o’clock on Monday morning in the large boardroom on the twelfth floor. Six people were in the room and four on the screen at the far end, their faces in small rectangles of varying quality. One was clearly in a hotel room. Another was in a car.
Maya was not invited to sit at the table. A chair had been placed against the wall near the door, slightly behind Kalu, and she was told she’d be asked to speak at the appropriate point. Marcus hadn’t been invited at all. He was downstairs in the lobby café with his thermos, reading the Financial Times. When she’d left him he’d said only, “They’ll try to make it about whether you’re credible. Don’t let them. Make it about whether it’s true.”
The chair was a man called Jonathan Pell, a former permanent secretary with a soft voice and perfect manners. He opened the meeting by summarising the Guardian article, the regulator’s call and the decision to bring the full board meeting forward to Thursday. Then he asked Ashworth to give an update, and she did, in the smooth register Maya now knew was her armour. We are taking this extremely seriously. An independent investigation is under way. The Assistant was not involved. We expect preliminary findings by Thursday.
Then Pell turned to the screen.
“David, I think you wanted to come in.”
David Strand was a non-executive director. He’d spent twenty years in private equity before moving into healthcare boards, and he was dialling in from what looked like a very large kitchen. He had a broad, impatient face and the habit, Maya noticed straight away, of starting to talk slightly before the previous speaker had finished.
“Thanks, Jonathan. I’ll be brief, because I think this is quite simple and we’re in danger of making it complicated.” He leaned towards his camera. “We’ve had a serious incident. A patient nearly died. We know which change caused it, because Deborah’s told us, and we know who made it. I’ve read the timeline. A junior engineer removed some safety-critical code he didn’t understand. I’m sorry for the lad, I really am. But I don’t understand why, nearly two weeks later, we haven’t taken any action in relation to that individual, and I don’t understand what we’re going to say to the regulator on Thursday if we still haven’t.”
Ashworth said, carefully, “We’ve commissioned an independent investigation, David, and I didn’t want to pre-empt—”
“I understand that. And I’m sure the investigation’s very thorough.” He didn’t look at Maya, though she was fairly sure he knew where she was sitting. “But a thorough investigation that concludes nobody’s responsible is not a message I can stand behind. Shareholders won’t stand behind it. The regulator won’t. And frankly, if I were Mr Hale’s family, I wouldn’t either.”
Pell turned to the wall. “Ms Reyes. Perhaps you’d like to respond.”
Maya stood up. She’d thought about sitting, and decided that if she was going to be talked about as a chair against a wall she’d rather be a person standing.
“Thank you. I’d like to correct one thing first, if I can. The investigation hasn’t concluded that nobody’s responsible. It’s concluded that a lot of people are, and that most of them aren’t in this building and never touched the code.” She’d planned the next part on the Tube, and it came out more steadily than she’d expected. “The engineer made the change, yes. But I think it helps to know how software is written at Meridian now. Engineers mostly don’t type the code themselves any more. They describe what they want to an AI tool, the AI writes the code, and the engineer checks it. That’s how Meridian has asked them to work for the last two years. This engineer did exactly that, and he checked every line. The AI was following a set of written instructions from Meridian’s own library, and over the past year several people had edited those instructions until they no longer told it to stop and ask before deleting anything. Last summer, to save money, his team had also been moved to a cheaper version of the AI, which looks at less of the system at once. It never saw the one file that showed the code was still in use. A senior engineer then approved the change in four minutes, which is Meridian’s normal practice. The code he removed had been undocumented for nine years. The only other safeguard, the lab phoning the ward, was switched off in 2019. Eleven months ago, a senior engineer raised this exact failure in your risk register. It was downgraded, summarised into a green bullet point for the steering group and scheduled behind feature work. A few months later her performance rating was lowered.”
“Yes, I’ve read the summary.” David waved a hand at his camera. “There’s always a history, Ms Reyes. There’s always a memo nobody read. That’s in every incident report I’ve ever seen. In the end, somebody pressed the button.”
“Then which somebody?” Maya said.
He looked at her properly for the first time.
“I’m sorry?”
“If it has to be somebody, which one? The engineer who pressed the button? The reviewer who approved it? The team lead who moved his team onto the cheaper AI, and turned down the senior engineer’s request to check changes to that part of the system? The people who edited the AI’s instructions until it stopped asking before it deleted things? The steering group that didn’t read the paper? The investment committee that tripled the AI budget without a risk section?” She kept her voice level. “I can give you any one of those names by Thursday, and I can make each of them sound like the cause. They all did something that, with hindsight, contributed. But if you remove any one of them, the others are still there. This happens again, to a different patient, through a different person. I’ve found eleven places in this organisation that do patient matching, and four of them may have the same weakness. You won’t fix that by exiting a twenty-four-year-old.”
There was a small silence on the line.
“All right,” David said. “Then the team lead. Whitfield. He made the cost decision, he declined the review request, and he runs the team. If you’re telling me the junior is a victim of his circumstances, fine. Whitfield created the circumstances.”
“Josh Whitfield was told by the Chief Digital Officer’s office to cut spend by thirty percent. He was measured, and rewarded, on throughput. He did what he was rewarded for, extremely well. His dashboards are the ones this board was shown last year as evidence of the programme’s success.” Maya didn’t look at Felix, but she felt him go still at the far end of the table. “If you want to hold Josh responsible for doing what the organisation asked of him, you have to hold the organisation responsible for asking.”
“That’s a very convenient position for a consultant.” David’s voice had cooled noticeably. “Everybody’s responsible, so nobody is, and the board pays for a long report.”
“It’s not convenient,” Maya said. “It’s the most inconvenient finding I could possibly bring you. A name would be much easier for everyone, including me.”
“Then perhaps you should consider whether you’re the right person for this engagement.” He said it pleasantly, and it was not pleasant. “Jonathan, I’d like it minuted that I have serious concerns about the direction of the investigation. If Ms Reyes isn’t able to bring the board a clear, actionable account of accountability on Thursday, I’d suggest we look at whether a different firm can.”
Maya felt it go through her, cold and precise. It wasn’t fear exactly. It was more like a client’s floor dropping a few inches beneath her feet. She knew very well what this meant for her. Kestrel’s biggest healthcare client would be lost, and she would be the senior consultant who’d lost it. Graham would take a call this afternoon. And she would have a reputation that had been built over eleven investigations on exactly the opposite: on knowing when to give the client what it needed in order to close.
She also knew, with total clarity, that she wasn’t going to give him a name.
“That’s your decision to make,” she said. “But I’d ask the board to hear what I bring on Thursday before making it. And I’d like it minuted too that I’ve been asked to name an individual, and declined, because on the evidence I don’t believe it would prevent a recurrence.” She looked at Pell. “If the board wants a name rather than an answer, I’m not the right person. I’d rather say that now than on Thursday.”
The silence this time was longer.
Then Ashworth spoke. She didn’t look at Maya. She looked at the screen, at David’s broad impatient face in its rectangle.
“David, I commissioned Ms Reyes. I’ve seen enough of what she’s found to know I don’t want to stand in front of the regulator having ignored it. I’m not prepared to replace the investigator three days before she reports because we don’t like the shape of the finding.” She paused just long enough. “She presents on Thursday. If the board isn’t satisfied then, we’ll discuss accountability, including individual accountability. I’ll bring that discussion myself. But not before.”
It was not, Maya noted, an endorsement. It was a deferral, carefully hedged, with an exit built into it. But it was a deferral in her favour, made out loud in front of the full board. Ashworth hadn’t had to make it.
“Fine,” David said, after a moment. “Thursday.” He sat back in his kitchen. Maya saw him write something down. She had a feeling it was a note to himself about a decision he intended to come back to, whatever Thursday brought.
She found Marcus in the café, where he’d moved on from the Financial Times to the crossword.
“Well?”
“A non-exec called David wants a name. He tried Sam, then Josh, and when I wouldn’t give him either he suggested the board find a different firm.” She sat down. Her hands were shaking slightly, and she put them flat on the table. “Ashworth held him off until Thursday. Just.”
“Good. That’s about what I’d expected.” Marcus folded the newspaper. “Did you offer to resign the engagement?”
“More or less.”
“Did you mean it?”
“Yes.”
He looked at her over his glasses.
“Then let’s go for a walk,” he said.
They walked out through the back of the building and down the steps to Paddington Basin, the long stretch of canal water behind the offices. They went past the coffee kiosks and along the water towards the little bridges that curled up and opened for boats. It was cold and bright, the first dry morning in a week. Maya walked with her hands in her coat pockets and didn’t say anything for a long while, and Marcus let her.
At the end of the basin, by the railings, she stopped.
“There’s something I’ve never told you,” she said.
He waited.
“Eight years ago, my first solo investigation. A press shop in the Midlands. Halden Components. A near-miss on a stamping line. A setter put his arm into a press that should have been locked out, and it cycled, and he pulled his arm out with about a quarter of a second to spare.” She looked at the water. “I was very good. I found the shift supervisor, Alan Pryce. He’d signed off the lockout check without doing it, because they were behind on an order and he wanted the line back up. It was all there in black and white. Signature, timestamp, no physical check. I wrote it up beautifully. Root cause: supervisor failed to follow lockout procedure under time pressure. Recommendations: disciplinary action, retraining, a new sign-off form. It was a model report. Graham used it in pitches for three years. It made my career.”
Marcus said nothing.
“What I didn’t write,” Maya said, “because it was messy and the client didn’t want it and I had a clean answer already, was that every supervisor on every shift at that plant was signing the form without doing the check. Because the targets made it impossible not to, and everybody knew, and the managers knew. They’d built a plant where the procedure could only be followed by people who were willing to miss their numbers. I saw it. I saw it in the interviews. I had a sentence in my notes, from one of the setters: everyone signs it, love, you’d never get anything done. I didn’t put it in the report.” She stopped. Her voice was very controlled. “Eighteen months later, at their sister plant in Telford, a setter called Gary Holt was killed in the same kind of press. Same form. Same signature without the check. Same targets.”
The wind came off the water. Somewhere behind them a train pulled out of Paddington.
“I read about it in the trade press,” she said. “Nobody connected it to my report. Why would they? My report said it was Alan Pryce. And Alan Pryce had been dismissed by then, so the problem was solved.”
She took her glasses off and wiped them on her scarf, and put them back on. Her hands had stopped shaking.
“So that’s why,” she said. “When David asked for a name this morning, that’s what I was looking at. That’s why I won’t.”
When Marcus spoke, it was gently.
“Thank you for telling me.”
“You’re not going to tell me it wasn’t my fault?”
“No.” He looked at the water too. “It was partly your fault. You saw it and didn’t write it down, because you were young and good, and the client wanted a clean answer. That’s a real thing you did. But you weren’t the one who built the plant.” He paused. “I’ve got one of those as well. You’ve met her. She cooks.”
Maya looked at him.
“Aiko,” she said.
“Aiko wrote everything down. I put it in an appendix. Nobody read it, and I didn’t push. She’s spent twenty-eight years making the best food in London in a room with eight seats because of what I didn’t push for.” He turned from the railings. “Which is why, when you told me on the phone that there was a woman at Meridian who’d written it all down and been moved to test tooling, I got on a train.”
They walked back along the basin in silence. At the bottom of the steps up to the building, Marcus stopped.
“You’ve got three days,” he said. “You’ve got enough evidence. What you haven’t got is something Ashworth can do on Monday morning. She was right about that, on Friday, you know. She’s a good chief executive. Being right isn’t the same as being useful.”
“I know.”
“So tonight we’re going to dinner.”
“Marcus.”
“I’m not joking.” He started up the steps. “You’ve been looking at this from the inside for two weeks. You’ve seen everything that’s broken. Now you need to see something that isn’t.” He glanced back. “Half seven. Don’t be late.”