Our maternity investigation programme is part of a national action plan to make maternity care safer. We are undertaking approximately 1,000 independent maternity safety investigations to identify common themes and influence systemic change.
We have been tasked with carrying out these maternity investigations because we are in a unique position as a national and independent investigating body to:
- Use a standardised approach to maternity investigations without attributing blame or liability.
- Work with families to make sure we understand from their perspective what has happened when an incident has occurred.
- Work with NHS staff and support local trust teams to improve maternity safety investigations.
- Bring together the findings from 1,000 reports to identify themes and influence change across the national maternity healthcare system.
All NHS trusts with maternity services in England refer incidents to our team.
We’ve made some changes to the way we carry out maternity investigations due to the Covid-19 pandemic. We have reviewed our approach to minimise the impact our work has on NHS maternity services during this time.
The main changes are:
- A review of what we investigate. We no longer routinely investigate maternity cases involving cooled babies where there is no apparent neurological injury following cooling therapy. However, it is important to note that NHS trusts should continue to refer all cases that meet HSIB criteria to us.
- We are no longer carrying out face to face interviews. Where possible we are using video technology such as Skype or Microsoft Teams to speak to the families and NHS trust staff involved in our investigations.
Many of our maternity investigators are midwives who work with us on secondment from their NHS trust. We recognise the current increased pressure on maternity services and have made a commitment to enable our team members to return to clinical practice at their trust, should there be a request to do so.
More information about changes to the way work as a result of Covid-19 is available on the information for families page and the information for trusts and staff page. If you’ve got any questions or concerns, please contact us by email at firstname.lastname@example.org.
The National Maternity Safety Ambition - launched in November 2015 - aims to halve the rates of stillbirths, neonatal and maternal deaths, and brain injuries that occur soon after birth, by 2025. This strategy was updated in November 2017 with a new national action plan called Safer Maternity Care, which set out additional measures to improve the rigour and quality of investigations into term stillbirths, serious brain injuries to babies and deaths of mothers and babies.
The Secretary of State for Health asked HSIB to carry out the work around maternity safety investigations outlined in the Safer Maternity Care action plan. Soon after the action plan was announced our implementation team developed our approach and investigation methodology, and started to recruit maternity investigation teams. Directions were tabled in parliament to give HSIB the remit to conduct the maternity investigations programme. Our work started in April 2018 and we achieved full national coverage in April 2019.
You can get in touch with our maternity investigation team by email at email@example.com.