Our investigations follow a thorough, independent and impartial process. Like our national investigations, they are characterised by a focus on learning and not attributing blame. The involvement of the family is a key priority.
Our maternity investigations:
- Identify the factors that may have contributed towards death or harm.
- Use evidence-based accounts to establish what happened and why.
- Make safety recommendations to improve maternity care both locally and nationally.
- Make the referral and upload the case note to HSIB’s secure Maternity Investigation Database and Support System (MIDAS).
- If the trust has reported this as a serious incident (SI), the trust remains responsible for completing a 72-hour report and StEIS (it’s a national requirement that serious incidents are reported using the Strategic Executive Information System within three days).
- 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.
Inform the family
- When a case meets criteria for referral, inform the family and provide further information about us, including the HSIB family card.
- Where appropriate complete duty of candour.
- Scan all relevant notes relating to the case and upload to MIDAS.
- Identify and support staff involved in the case.
- Provide staff with information about us, including the staff information leaflet.
Acknowledge receipt of referral
- Phone trust within one working day.
- Provide trust with further information they need about the family for the investigation.
- Contact the family within five working days. This happens after the trust have informed the family about the referral and where required completed duty of candour.
- Obtain verbal consent and establish communication approach.
- Arrange an initial meeting at an agree location.
- Keep family informed of investigation progress.
- We will visit trusts a number of times during an investigation.
- Review notes and evidence.
- Meet and interview the staff involved.
- Work with the trust to identify immediate risks.
- Subject matter advisor review team (SMART) review.
- Agree terms of reference for the investigation and send to the family and the trust.
- Identify gaps in evidence.
- Consider findings and potential safety recommendations.
- Organise second SMART review.
- Keep trust informed of investigation progress.
- Draft report reviewed at report panel. Report panels may be attended by relevant clinical subject matter advisors who provide advice and guidance to the investigation team.
- Draft report shared with trust and staff involved to check for factual accuracy.
- Draft report shared with the family to check for factual accuracy.
- Final report shared with the family.
- Final report shared with the trust, NHS Resolution and other appropriate organisations. It is the trust's responsibility to share the report with the local clinical commissioning group (CCG).