Find out more about our maternity investigations below. We'll be updating all the information as the programme progresses.
In November 2017, the Secretary of State for Health published a refreshed National Maternity Safety Strategy Safer Maternity Care announcing plans for HSIB to undertake around 1000 independent safety investigations.
HSIB will investigate cases of intrapartum stillbirth, early
neonatal deaths and severe brain injury diagnosed in the first seven days of
life, when the baby:
diagnosed with grade III hypoxic ischaemic encephalopathy (HIE); or
therapeutically cooled (active cooling only); or
decreased central tone and was comatose and had seizures of any kind.
We’ll also investigate direct or indirect maternal deaths in the
Until HSIB formally notifies providers of the start date and
referral process, serious incident investigations into maternity events that
meet the specified criteria must be investigated as normal by the host organisation.
Our investigations will continue to be characterised by a focus on learning and not attributing blame, and the involvement of the family is a key priority.
Sharing learning from these local investigations is crucial and as an independent national body we will build a bigger picture of the issues and generate wider recommendations for the system.
identify the factors that may have contributed towards death or harm
use evidence based accounts to establish what happened and why.
We will work alongside staff in the affected organisation, as local and clinical knowledge is key to building our understanding as well as offering support and guidance on investigative techniques and practices.