Why is HSIB carrying out maternity investigations?
HSIB can bring standardised approach to maternity investigations and won’t attribute blame or liability. HSIB will set out the facts of what happened in each case and generate recommendations and aggregate the findings from reports and draw out wider learning for the whole system.
What is the plan for the rollout of maternity investigations?
HSIB will have a phased national roll out (national coverage by March 2019). The regional split will broadly be
South (three teams)
Midlands and East (four teams)
London (three teams)
North (four teams)
Four teams have completed training and are now in place.
HSIB has recruited over 100 of the 120 posts for the remaining maternity investigation teams. These investigators have been allocated to one of the six training courses by March 2019. The remaining maternity investigators to be recruited will also complete their training by March 2019. Eventually 14 investigation teams will cover the whole of England. The 14 team leaders are already trained and in place.
Do organisations where the incident occurs still conduct their own investigation?
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.
HSIB maternity investigations will eventually replace these internal serious incident investigations on a rolling basis. A process will be established to involve the local organisation and share the investigation reports as they are completed.
Host organisations will continue to investigate maternity events that fall outside the specified criteria.
Who are the maternity investigation team?
HSIB is conducting a large-scale recruitment campaign and expect this will enable a wide range of experience and skill to be identified in potential investigators. The teams will be made up of multi-disciplinary professionals who have all had investigation experience. This will be further developed through our tailored investigation programme. The wider maternity investigation team will include clinical experts in obstetrics, neonatology, anaesthetics and midwifery. As with our all our investigations, we will also bring in specific subject matter experts where needed, for example; mental health.
Our Senior Team is made up of a Clinical Director, Associate Director of Maternity Investigations, two Heads of Maternity Investigations and four clinical advisors.
What will HSIB investigate?
HSIB will undertake maternity investigations which meet the following criteria;
Eligible babies include all term babies (at least 37+0 completed weeks of gestation) born following labour who have one of the following outcomes;
Intrapartum stillbirth: where the baby was thought to be alive at the start of labour but was born with no signs of life.
Early neonatal death: when the baby died within the first week of life (0-6) days of any cause.
Severe brain injury diagnosed in the first 7 days of life, when the baby:
- Was diagnosed with grade III hypoxic ischaemic encephalopathy (HIE); or
- Was therapeutically cooled (active cooling only); or
- Had decreased central tone and was comatose and had seizures of any kind.
Maternal Deaths: Direct or indirect maternal deaths in the perinatal period (during or within 42 days of the end of pregnancy). Coincidental maternal deaths will not be investigated.
How are maternity incident referrals going to be made to HSIB?
Referrals will be made directly by Trusts to HSIB and a secure system is now in place.
What will the maternity investigation report look like?
A HSIB maternity investigation report will include the terms of reference, the process of investigation, the evidence and recommendations for improvement both at an organisational and national level.
Who is going to have ownership of recommendations?
Safety recommendations may be made in HSIB reports and they will be addressed to those the HSIB consider best placed to address the identified deficiencies. HSIB will also report on any safety action that may have been taken as a result of the maternity event.
How will wider learning be shared?
HSIB will analyse the findings of the investigation reports and safety recommendations to identify recurring themes. HSIB's national teams may then investigate these themes further and share the data with regulators and professional bodies who could implement change at a national level.
Who will see the final reports?
Reports concerning individual cases will only be shared with the family, the organisation, and clinicians and midwives who were involved in the incident. On this website, thematic reports will be published. These will not identify individual cases or Trusts.
How are families going to be involved in HSIB investigations?
HSIB will involve families throughout the investigation and are in the process of developing an effective family engagement service.
How independent are HSIB in their investigations?
Although funded by the Department of Health and Social Care and hosted by NHS Improvement, HSIB is operationally independent. HSIB is also separate from all the regulatory bodies like the Care Quality Commission (CQC). There is draft legislation currently going through parliament that once adopted, will complete our transition to a fully independent body.
Are individual staff required to engage with HSIB investigation?
Yes, individual staff are obliged as per their professional codes of conduct to engage in investigations. If staff are asked to interview, they are welcome to bring someone with them for support.
Will providers still be completing the Perinatal Mortality Review Tool (PMRT)*, if the incident is referred to HSIB?
Yes, the PMRT is a separate tool designed to support high quality standardised perinatal reviews and is part of the National Audit Programme. This is separate to the maternity investigations being undertaken by HSIB. However, in agreement with PMRT, HSIB will work collaboratively to complete the tool.
Recognising organisations may feel the burden of reporting, HSIB will endeavour to work with system partners such as MBRACE, and the Royal College of Obstetricians and Gynaecologists to streamline this process