This “independent diagnostic assessment”, which began in January, included stakeholder interviews, document analysis and surveys of HSA patients and caregivers, staff and external partners. The report is littered with words such as “ineffective”, “weak”, “suboptimal” and “poor” when the consultants talk about the challenges with management, governance, oversight and performance. The report identified oversight weaknesses in operational performance and risk management, as well as numerous weaknesses in the HSA management team and the board. “The report gives us an evidence base from which to strengthen governance, clarify responsibilities and improve accountability across the system. We will work with the HSA Board and leadership to ensure that recommendations are considered systematically, that responsibilities are clear and that progress can be monitored,” she added.