We work with women and their families, the maternity teams who care for them and the risk and safety teams at the trust on maternity investigations.
We investigate incidents that meet the Each Baby Counts criteria or our defined criteria for maternal deaths. Each Baby Counts is the Royal College of Obstetricians & Gynaecologists’ national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. You can find more information about our referral criteria on the what we investigate page.
We’ve made some changes to the way we carry out maternity investigations due to the COVID-19 pandemic.
The following frequently asked questions aim to help explain these changes for NHS trust staff. If you’ve got any questions or concerns that are not answered below, please contact us by email at firstname.lastname@example.org.
Why is HSIB continuing to carry out maternity investigations during the outbreak of COVID-19?
As requested by the Department of Health and Social Care (DHSC) we will continue to investigate the more serious maternity cases, which meet the Each Baby Counts (EBC) criteria.
Why is HSIB not progressing all cases?
We have been reviewing our processes and approach to investigations to ensure we minimise the impact our work has on maternity services.
Additionally, in recognition of the pressure of COVID-19 on the NHS and maternity services we have made a commitment to enable our maternity investigation team, some of whom have been called back to clinical practice, to do so as soon as they are required.
What part of the criteria has HSIB changed?
Since 23 March 2020, we have no longer been routinely investigating maternity cases involving cooled babies where there is no neurological injury following cooling therapy. This would normally mean a brain MRI showing no hypoxic damage and the baby demonstrating no ongoing neurological signs or symptoms.
Do trusts still need to refer all incidents which meet the EBC criteria to HSIB?
Yes. We request that trusts continue to refer all cases meeting the criteria in accordance with the HSIB Maternity Investigations Directions 2018. These cases will be reviewed on an individual basis. In cases where no damage is seen and no concerns are raised by the trust or family, we will log the event and not progress an investigation further. We will also inform trusts that there is no expectation for them to carry out a full investigation.
During the outbreak of COVID-19 do trust staff still need to take part in interviews?
We are taking a pragmatic approach with interviews. Where possible we will still invite staff to be interviewed remotely using video technology such as Skype or Microsoft Teams. We value staff input whilst respecting the clinical challenges on the frontline.
During the COVID-19 pandemic will consideration be taken when reviewing clinical practice that may fall short of normal national guidance?
Yes. Consideration will be taken when reviewing incidents which occur during the outbreak of COVID-19. For example, the impact of wearing personal protective equipment. We will take a pragmatic approach to each incident and where possible benchmark against new local or national guidance.
If I have a concern or query who can I contact?
You can contact us by email at email@example.com.
Our maternity investigations have replaced the trust’s internal maternity serious incident investigations. We involve the trust and share the investigation reports as they are completed. Trusts continue to investigate maternity events that fall outside the specified criteria. Find out more about these criteria on the what we investigate page.
If the incident meets the criteria of a serious incident in accordance with the Serious Incident Framework (2015) the trust is still responsible for the Duty of Candour, 72 hour report and reporting to the Strategic Executive Information System (STEIS).
In addition, the incident should be reported to Each Baby Counts, NHS Resolution – Early Notification Scheme and MBRRACE-UK where required. Where cases meet the criteria for reporting to the Perinatal Mortality Review Tool, we complete this in collaboration with the trust once the investigation is complete.
We make sure that trust staff are fully informed of the legal obligations we operate under and how this aligns with their professional responsibilities during investigations.
We also make sure that staff are supported throughout the investigation process. Our highly trained investigators ensure compassion and respect when we’re working together to build local and clinical knowledge during an investigation.
During our investigation trust staff may be asked for statements by the coroner.
Staff interviews help establish the facts about the incident.
Supporting staff is a priority. We make sure they're fully informed of their legal obligations, the legal environment we operate in and how this aligns with their professional responsibilities within an investigation.
Our interviews are based on open questions, although there will always be some more direct questions.
Our interview approach is not about finding or apportioning blame, neither are our reports. We achieve this by describing what happened and how things can be done differently to prevent a repeat in the future. There is no blame or liability directed against individuals.
If staff are asked to attend an interview, they are welcome to bring a colleague with them (but not a family member or friend).
We obtain consent from staff before recording an interview.
We recognise that staff may be anxious about having their discussions recorded.
We understand that regional officers of The Royal College of Midwives (RCM) advise local stewards that audio recording of interviews is preferable. The medical defence unions (Medical Protection Society, Medical Defence Union and Medical and Dental Defence Union of Scotland) also recommend audio recording for interviews.
Feedback and reports
Investigators don't feedback to staff during the investigation. Once the report is produced it’s available for staff to read. We hope that the trust will provide a feedback and learning session for all staff.
We don't name individuals in our report, or give the grade of an individual, unless it’s relevant to understanding the circumstances of the incident.
We believe that through our investigative approach we will reduce the likelihood of unfounded concerns being raised about individuals, by explaining the circumstances of the incident and the role of any given individual in the process.
NHS Resolution provides expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care.
Information for staff and trusts
These documents help trusts to explain who we are and what we do, to the staff and families involved in maternity investigations.
If you would like to request any of these documents in another format, please email firstname.lastname@example.org. Other formats include easy read, large print, braille, or any other language or need.
Family card (PDF)
Family card in other languages
The family card is available to download in these languages: