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 130 NHS trusts with maternity services in England refer incidents to our team.
What we've done
As of September 2019 we have:
- Received 1,035 incident referrals.
- 490 active maternity investigations.
- Completed 125 maternity investigations.
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 firstname.lastname@example.org.