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.

We aim to complete maternity investigations within a reasonable timeframe not exceeding six months.

We hope that the number of cases referred to us for investigation under the current criteria will reduce over time, if we are successful in improving maternity safety through our recommendations and sharing our learning. 

Key points to note:

  • During our investigation trust staff may be asked for statements by the coroner.
  • We don't get involved in any litigation - our purpose is solely to learn. 

When a maternity incident occurs

Trust responsibilities

The trust’s responsibilities are to: 

  • Immediately review the circumstances of the case to determine whether it falls within scope of the Each Baby Counts criteria (this must be thoroughly considered). 
  • Continue with their early risk management/patient safety review process.
  • Undertake a 72-hour report for any case that is designated as a serious incident (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.
  • Provide the family with advice about HSIB’s role in conducting the investigation, including an HSIB family card.
  • Gain the family’s verbal consent to make the referral to HSIB. This includes consent to provide us with contact information for the family, before the referral is made. 
  • Once consent has been received from the family, make the referral and upload the case note to HSIB’s secure Maternity Investigation Database and Support System (MIDAS). 

HSIB responsibilities

Our responsibilities are to:

  • Assign an investigation team consisting of a coordinating investigator and a supporting investigator to the referral.
  • Contact the trust within one working day of the referral being made, to verbally confirm consent has been given by the family to view their case notes.
  • Contact the family within five working days to verbally confirm their willingness for us to conduct the investigation and to participate by giving evidence.

Gathering and analysing evidence 

  • Once we have confirmed consent from the family to conduct the investigation we make an initial visit to the trust. This usually takes 1-2 days. During the visit we identify key staff to support the investigation. We follow up with further visits to record interviews with staff. 
  • Each family has the opportunity to set the frequency of contact with the team throughout the investigation. This is usually around every two weeks, but reflects the needs of each individual family.
  • We visit the family at least twice during evidence gathering if possible. First to introduce ourselves and discuss the investigation process, and then to conduct our recorded interview. 
  • Once the initial interviews with the family are complete and the case notes reviewed, we hold an internal clinical review panel to discuss and scope the case. Subject matter advisors support our investigation and analysis when needed to ensure a full understanding of the case. 
  • Once all interviews are complete we hold a second clinical review panel with the relevant advisors. We discuss the findings and recommendations identified for inclusion in the investigation report.
  • The family and the trust then review the draft report for factual accuracy. Any concerns can be discussed at this point. If they feel that there is an unfair bias, then this is considered by the review team and changes made if agreed. 
  • All of our maternity reports are anonymous and don’t identify the patient, family, trust or the staff involved. 
  • We update the family and the trust on a regular basis throughout the investigation process. 

Investigation completion

  • The report is finalised and shared with the family, trust and healthcare professionals who were involved in the incident. 
  • The final quality assurance process takes around a month from the start of the process and the release of the final report in which we make evidence-based safety recommendations to improve maternity care.
  • Unlike our national investigation reports, we don’t publish individual maternity investigation reports. The reports are the property of the family and the trust. They are free to use the report without restriction for their own purposes.
  • The trust can share the report with their clinical commissioning group.
  • We ask the family to share their experience of the investigation with us by completing a family feedback questionnaire.
  • The NHS Improvement perinatal mortality review tool is completed in collaboration with the trust after the investigation has finished, if applicable.