Cayman’s Health Services Authority (HSA) has no shortage of governance machinery. It has legislation, a board manual, committees, executives, policies, strategic plans and performance reports. What an independent KPMG assessment published by Government on August 6 finds lacking is something more fundamental: clarity over who makes decisions, reliable oversight of performance and risk, and accountability when things go wrong.

The review identifies 11 challenges and proposes 47 improvements across strategy, governance, accountability, communication and culture. Among its findings, 58% of surveyed staff and external partners say it is “not very” or “not at all” clear who is in charge of decisions within leadership, while 51% of staff respondents report limited or no comfort expressing concerns without fear of consequences.

Government’s answer is an ambitious overhaul. Katherine Ebanks-Wilks MP, Minister for Health, Environment & Sustainability, says all 47 recommendations are priorities. A Governance Implementation Steering Group is promised within three months, public progress reports every six months, a new Chief Operating Officer over the medium term and, separately, an independent clinical and operational review.

“When we commissioned this assessment, I committed to making the findings available to the people of the Cayman Islands. Publishing the report in full is an important part of that commitment,” Minister Ebanks-Wilks says.

Publication deserves credit. Governments are not always eager to publish reviews containing findings such as these. But transparency is the beginning of accountability, not its conclusion, and the harder question is what the report actually tells Cayman about the way its largest public healthcare provider is governed.

The transparency, however, has a limit. The 51-page report does not disclose how much the Government paid KPMG for the assessment. It says KPMG LLP was engaged by the Ministry on 17 December 2025 and describes its role as providing advisory and analytical support, including stakeholder engagement, research, analysis, facilitation and benchmarking, but gives no contract value or professional fee.

That omission is particularly noticeable given the Ministry’s emphasis on publishing the review “in full” in the interests of transparency. The cost of commissioning the work does not determine the validity of KPMG’s findings, but it is basic information about the expenditure of public money and would allow taxpayers to judge the cost alongside the scope and value of the exercise.

Who governs whom?

Start with the most basic question in any organisation: who is responsible for what? KPMG finds that roles are defined on paper but are not sufficiently clear in practice. The Public Authorities Act, HSA Act and board manual establish responsibilities, but limited guidance on how those responsibilities should operate creates uncertainty. The board manual also lacks sufficient detail about when serious matters should move from executives to the board and from the board to the Ministry.

More strikingly, KPMG reports that board involvement in day-to-day operations “blurs boundaries”, contributes to role confusion, slows decision-making and weakens the perceived authority of executive leadership. Stakeholders report board members who previously held HSA executive roles engaging directly with frontline staff and making requests outside formal management channels. Executives, meanwhile, reportedly seek directors’ involvement because of capability gaps.

It is a circular problem: directors reach down because management needs support; management reaches up because directors are already involved. The result is precisely the kind of organisation in which plenty of people can participate in a decision while responsibility for it becomes harder to locate. That is more than an untidy organisation chart; it erodes the distinction between governing a public authority and running it.

Minister Ebanks-Wilks is careful to draw a boundary around that conclusion.

“This assessment examines governance structures and processes, not the performance of any individual, past or present. What it does do is set a standard.”

That distinction matters. KPMG is not conducting a disciplinary investigation and its findings should not be converted into allegations against unnamed individuals. But some of what it describes is behaviour rather than architecture. Systems do not bypass management channels, conduct business over WhatsApp - where KPMG says decisions were reportedly made “without documentation” - or make inappropriate comments. People do. New rules may make the boundaries clearer; accountability requires people to observe them.

The review does not arrive in a vacuum

KPMG’s assessment lands after years in which HSA has repeatedly faced questions over accountability, internal controls, public money, patient and staff protection and the conduct of people working within the organisation.

The most obvious governance controversy involves its board. Between January 2022 and June 2023, directors held 190 meetings generating almost CI $491,000 in stipends, according to Government figures. The per-meeting system was subsequently scrapped after Government said costs had been allowed to escalate without a corresponding increase in accountability or value for money. An internal audit later identified weaknesses around board remuneration and recommended that some payments be recovered.

Other episodes concern operational controls. In 2025, HSA disclosed that equipment intended to vent fumes during the preparation of chemotherapy treatments had not been connected to the hospital pharmacy’s external ventilation system. Officials could not say how long the problem had existed. The pharmacy was closed, potentially affected staff were assessed and an external expert was brought in to investigate; HSA said it was unaware of specific illnesses and that patients were not potentially exposed.

The previous year, HSA placed senior pharmacy personnel on required leave and terminated another employee while investigating alleged breaches of pharmacy procedures and controls. HSA said the investigation was being conducted with police, while the then board chairman said Government Internal Audit would also be involved. The allegations against individuals should not be treated as established wrongdoing.

More recently, Legionella bacteria have been detected at hospital water outlets, while separate police and court matters have involved current or former HSA personnel, including allegations concerning access to confidential medical information and immigration documentation. A former pharmacy technician has also been imprisoned following criminal convictions. Those cases differ substantially in their facts and legal status, and neither an arrest nor an accusation establishes guilt.

Nor does every episode involving HSA point towards institutional failure. Former security employees accused of overtime fraud were acquitted, and some of the controversies surrounding HSA stretch back through different boards, governments and legal regimes. They cannot fairly be bundled together as proof of KPMG’s conclusions.

What they do provide is context. The question raised by the governance review is not whether bad governance caused every incident associated with HSA. KPMG makes no such finding. It is whether the institution has sufficiently robust systems to identify problems early, escalate risks, preserve reliable records, establish who is responsible and ensure corrective action follows when controls fail.

Minister Ebanks-Wilks acknowledged that wider history when announcing the assessment in January, referring to a “longstanding public plea for greater accountability at HSA”.

A board can have plenty of information and still know too little

KPMG’s findings on oversight may be more consequential than the organisational-chart disputes. HSA has dashboards, committees and reporting arrangements, but KPMG concludes they do not operate as an integrated, proactive oversight system. Problems with data quality, consistency and integration reduce confidence in reporting and contribute to reliance on anecdote rather than evidence.

The CEO’s monthly operational report is criticised for limited focus on priority KPIs and key issues, uncertainty over data accuracy and a volume and format that can obscure matters requiring attention. Operational and clinical KPIs lack adequate targets, tolerances or escalation thresholds, limiting the board’s ability to judge performance and determine when intervention is necessary. Internal audit is weakened by the absence of a formal charter, unclear reporting lines and limited tracking of findings and management actions.

Minister Ebanks-Wilks says some of this is already changing. “The CEO's monthly operational report is already in place, but the current board wanted it to be strengthened. I'm pleased to hear, through Chairman Ridley, that it is now being streamlined for the benefit of both the board and the Ministry.”

That is useful, but KPMG’s criticism is not simply that directors receive too many pages. A board can drown in information and still know too little. What matters is whether directors can see, quickly and reliably, what is deteriorating, how far performance is from target, who owns the problem, what corrective action is under way and when the matter crosses a threshold requiring intervention. A shorter report without those things would merely make the weakness easier to read.

The 51% finding

The culture findings are harder to dismiss as administrative shortcomings. KPMG describes a perceived shift towards disengagement, criticism and risk avoidance rather than learning, openness and continuous improvement. Meetings are described as confrontational and critical, while trust is reported as low between executive leadership and the board and between executive leadership and the CEO. Most troublingly, 51% of staff respondents report limited or no comfort expressing concerns without fear of consequences.

The communication findings reinforce the concern. Established processes are reportedly bypassed on occasion, including decisions made through WhatsApp or without documentation. KPMG says reluctance to use formal reporting routes because of fear of retaliation results in some issues travelling through informal or personal channels instead.

An HSA staff member, speaking to The Caymanian Journal (TCJ) under strict anonymity, echoes the report’s description of a closed culture while making broader claims that TCJ has not independently verified.

“HSA is a tight-lipped organisation with about a million secrets buried. Some of which would shock the public. There are many things that need to be brought out into the open in hopes of holding them accountable.”

The allegation of undisclosed “secrets” goes beyond what KPMG establishes and should not be confused with a finding of the independent review. What KPMG does independently document, however, is an environment in which a substantial proportion of staff respondents say they are uncomfortable speaking openly and where fear of retaliation can divert concerns away from formal reporting channels. The staff member’s demand for greater openness therefore resonates with a documented weakness, even though the source’s wider allegations remain unverified.

That matters in any public authority. It matters particularly in healthcare, where institutions depend upon employees being prepared to challenge a decision or raise a concern before a risk becomes an incident. KPMG makes the connection itself:

“Low psychological safety discourages speaking up, limits learning from issues, and increases the likelihood that risks remain hidden until they escalate into serious incidents.”

One of Government’s highlighted quick wins is an annual HSA staff conference.

“We've seen similar models, such as the one my colleague in the Ministry of Education, Minister England, facilitates annually for educators,” Minister Ebanks-Wilks says.

A staff conference may have value, but it is difficult to see it as the first answer to the 51% finding. The more urgent test is what happens to the employee who raises an uncomfortable concern on Monday morning: who receives it, how independently it is investigated, what protects the employee from retaliation and what consequences follow if retaliation occurs. A conference can talk about culture. It cannot substitute for those protections.

This is not a clinical safety report

Minister Ebanks-Wilks is explicit.

“I want to make it clear that this was not a review of clinical care or quality of treatment that patients receive. That's a separate piece of work. This was specifically about governance, the structures and processes that sit behind the health system.”

That caveat should be taken seriously. KPMG does not establish that HSA provides unsafe clinical care, nor does it demonstrate that the governance weaknesses it identifies have caused patient harm. Government therefore edges beyond what this particular assessment proves when it told the press conference:

“Put simply, for patients, this will mean safer, more consistent care and a system that responds better when concerns are raised.”

Better governance should create conditions for safer care. It is not evidence that care is currently unsafe. The distinction also explains why the separate clinical and operational review matters so much. KPMG identifies weaknesses in the machinery intended to detect and escalate poor performance and risk. The next review must answer the question this one cannot: what, if anything, has that machinery failed to detect?

Behaviour is not a flowchart

Some findings are harder to explain through defective structures alone. KPMG reports inappropriate comments and dismissive behaviour, particularly at board level towards executive leadership, and meetings used to air personal grievances and direct hurtful comments at colleagues. Patients also report disrespectful attitudes from some clinical and administrative staff, with insufficient action taken to address them.

Here Government’s insistence that the assessment is not about individual performance deserves respect but also scrutiny. KPMG is not conducting a disciplinary investigation and its findings should not be turned into allegations against unnamed individuals. Yet a governance system ultimately depends upon how people behave within it. New manuals and reporting lines can make expectations clearer; they cannot manufacture professional conduct.

There is also an important temporal qualification, which Minister Ebanks-Wilks is keen to emphasise.

“This assessment represents practices up until December 2025 and does not encompass the current initiatives of our newly appointed board,” she says. The new board, she adds, “has already made significant improvements in governance and has streamlined management and reporting lines to enhance effectiveness”.

KPMG likewise repeatedly notes that a new board and subsequent changes must be considered when reading its findings. That means it would be unfair to assume every practice described in the assessment continues unchanged today, or to attach inherited practices automatically to current directors.

It would be equally premature to declare the problems solved. “Significant improvements” is presently Government’s assessment of its reforms, not an independent measurement of their effect. The new board deserves neither inherited blame nor unearned absolution. It deserves to be judged on what happens next.

The problem with 47 priorities

Perhaps the most revealing moment of the press conference comes when Minister Ebanks-Wilks turns to implementation.

“I also want to be clear that all 47 recommendations are seen as the ministry as a priority. None of them are being set aside. The only difference will be the timeline for implementation.”

There is an awkward irony here. One of KPMG’s findings is that HSA needs better strategic focus. Its proposed remedy is a quantitative impact-and-feasibility process to select just three to five critical priorities for the next 12 months.

Government can accept all 47 recommendations. It probably should, if it concludes each is sound. But accepting 47 recommendations and having 47 priorities are different propositions. Prioritisation means deciding not merely what matters but what matters most, particularly when management time, money and organisational capacity are finite.

The implementation machinery is already expanding.

“A Governance Implementation Steering Group will be established within the first three months to oversee this work. From there, we will develop a detailed action plan and align the necessary budget before beginning implementation of the priority initiatives.”

That sequence deserves watching. HSA has just been diagnosed with blurred accountability, weak implementation and organisational complexity. The answer now includes another steering group, a new executive position, new dashboards, surveys, risk systems, reporting arrangements, legislative reform and a staff conference. Many may be sensible. Taken together, however, they carry the danger of answering complicated governance with still more governance.

Enter the COO

The Chief Operating Officer could be one of the most important changes.

“We're introducing a critical new role: Chief Operating Officer, to strengthen accountability at the executive level and improve operational oversight,” Minister Ebanks-Wilks says. “This role creates a clear executive lead focused on the day-to-day operations of the Health Services Authority, ensuring that strategic decisions made by the leadership are consistently translated into action.”

The execution will determine whether it works. After KPMG found that 58% of surveyed staff and partners lack clarity over who makes leadership decisions, another senior executive improves accountability only if Government defines the division of authority unmistakably: budgets, reporting lines, clinical and non-clinical operations, performance targets, hiring authority and the decisions that remain with the CEO.

A new title creates another box on the chart. It does not, by itself, answer KPMG’s question about who is in charge.

Which committees answer to whom?

Another change announced at the press conference deserves more explanation.

“The subcommittees have now moved under the senior management team. As a result, the HSA board is now only required to meet once a month,” explained Minister Ebanks-Wilks.

That may be entirely sensible if operational committees that previously sat too close to the board have been returned to management. But after a report whose central finding is blurred boundaries, Government should publish the revised committee structure and make clear which functions have moved.

KPMG recommends robust board-level scrutiny of enterprise risk and stronger independent assurance, including clearer internal-audit reporting. Its proposed model gives the relevant board committee responsibility for scrutinising the risk framework, risk registers and assurance reporting.

The question is therefore not simply whether there are fewer board meetings. It is whether the new structure puts operational management where it belongs while preserving independent board oversight where it matters. If this reform is about clarity, the new reporting lines should be impossible to misunderstand.

Nearly 700 voices - but not an overall opinion poll

Government understandably emphasises the breadth of participation. The review includes 483 patient and caregiver survey responses and 203 responses from staff and external partners, alongside 24 stakeholder interviews and a review of 46 governance documents.

“This simply was not a desk-based review,” said Senior Policy Advisor Alanis Linwood. “It was informed by direct engagement with the people and organizations closest to the HSA.”

The survey evidence is substantial and is strengthened where it converges with interviews and documentary findings. But participation should not be confused with representative polling. The Ministry explains that the patient survey was made accessible through QR codes in HSA waiting rooms, TV screens, the HSA newsletter and printed questionnaires placed in secure collection boxes. Respondents chose whether to participate.

The percentages should therefore be understood as percentages of respondents unless the detailed methodology establishes wider representativeness. That does not make findings such as the 51% speak-up figure unimportant; it means they should be reported for what they are rather than inflated into estimates of every HSA employee or patient.

Government is in the report too

Nor can implementation become a story in which the Ministry fixes the board, the board fixes management and management fixes staff. KPMG says limited direction from the Ministry contributes to uncertainty about HSA’s role in Cayman’s wider health system, particularly regarding which services it should provide relative to the private sector.

KPMG recommends that the Ministry and HSA formally define that role and clarify expectations for collaboration with private providers. The Ministry therefore sits inside the governance system being examined, not above it. Its implementation plan should distinguish clearly between what the Ministry must change, what the board must change and what HSA management must change. “Working together” sounds collaborative; it is also how responsibility can become collective enough that nobody quite owns failure.

Chief Officer Tamara Ebanks puts the test well.

“The value of this exercise will ultimately be measured by the actions that follow it. 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.”

But monitoring implementation and demonstrating improvement are not the same thing.

Don't measure reform by 47 green boxes

Government has made one particularly useful commitment.

“Importantly, we are committing to updating the public on our progress every six months thereafter,” Minister Ebanks-Wilks says. “This won't be the last time you hear about this.”

Those updates will matter only if they measure more than implementation. A new speak-up policy can be marked complete; whether staff feel safer challenging decisions is harder to tick off. A risk register can be produced; whether serious risks are identified and acted upon sooner is what matters. A dashboard can be launched; whether directors spot deteriorating performance and intervene earlier is the test.

The same goes for culture. An annual staff conference can be held, photographed and entered into an implementation tracker. Whether the next employee with an uncomfortable concern feels able to raise it without fear of consequences will tell Cayman considerably more.

Completing 47 recommendations, in other words, is not the same as fixing the problems that produced them.

The confidence test

Minister Ebanks-Wilks says the exercise is “really about giving the country confidence that we are continuing to move healthcare forward in a positive direction”.

Confidence may be the desired result. It cannot be the measure of success.

Do staff know who makes decisions? Do they feel safer speaking up? Does the board know when performance is off track? Are audit findings followed through? Are risks escalated before they become crises?

If the answer to those questions improves, Government will have something more valuable than a completed implementation plan.

It will have evidence.

And after a report about blurred responsibility, the final test is simpler still: who owns the result when it doesn't?