The review covers everything from operational performance to planned developments in the coming year (2021/22.) There are key sections on family and NHS staff engagement – focusing on their experiences of working with us including how we gather their feedback and sharing direct quotes. The review also sets out how HSIB fits into the wider maternity picture, explaining the way we work with other organisations and the contributions we have made to high-profile initiatives, projects, inquiries and reports.
HSIB’s unique perspective is also highlighted in the review. Our national remit combined with the insight we have into local maternity services means we are able to identify emerging safety risks and themes that can be found across England. Over the last year, maternity investigation reports have contained 1500 safety recommendations to trusts , addressing an array of issues and the most frequent emerging themes. This includes:
- effective escalation of safety concerns about mothers and babies,
- clinical oversight,
- clinical assessment and monitoring,
- use of clinical guidelines influence the care provided,
- impact of pathways of care crossing healthcare boundaries.
Another key area to the report was the sharing of learning from individual trusts in maternity safety including examples of changes that have been undertaken. . We have recently developed and shared a newsletter with trusts from across England, providing examples of improvements made to their maternity services as a result of our recommendations. This represents the influence and impact that HSIB is having on the day-to-day operations of NHS maternity departments.
Sandy Lewis, Associate Director of Maternity says: “The publication of the HSIB maternity programme year review provides crucial details of the work that has been undertaken in the last year. We would like to thank all of those who have worked with us in the past year, sharing their experiences, insights and expertise.
“Many families have not only told us their stories but have also trusted our investigators to reflect their perspectives and share their experience. Trusts have responded promptly to this insight, this has contributed to improving safer care of mothers, babies and families across the country.
“Our work would not be possible without hearing the voice of the staff involved. This has been particularly important in a year which has seen unprecedented pressures on NHS frontline services. The importance of reflecting these changes that have been implemented at pace and the impact these have had on the provision of NHS care.
“The HSIB maternity programme continues to develop in our approach at local, regional and national level and look forward to opportunities to further share and influence the safety agenda within maternity care.”
Some key highlights from the review
- The HSIB maternity investigation programme commenced 760 investigations during 2020/21. At the end of March 2021 fewer than 5% of our investigations had exceeded the designated 6-month timescale.
- Families are central to our work. Without good, effective family engagement, we would be unable to hear a family’s story, reflect their voice and answer their questions. All families are invited to be part of their investigation and to date 87% have consented. Families have described how HSIB investigations have helped them to fully understand the circumstances of their case; to trust that the knowledge generated is fair, transparent, and independent; and to feel reassured that they have been an important part of the investigation.
- Non-English-speaking families have benefited from HSIB’s inclusive approach – we have produced our information resources in 25 languages other than English, used interpreters and translated 57 investigation reports into the family’s preferred language. We produce reports in other formats, such as audible, at a family’s request.
- Trusts tell us that HSIB investigations and recommendations are positively influencing safer maternity care. We support trusts to take ownership of the recommendations from our reports and instigate responsive changes. The regular information we produce for trusts about our maternity investigations has helped to improve the flow of patient safety communication across perinatal teams.
- HSIB works in collaboration with NHS England and NHS Improvement’s Maternity Transformation Programme to support the national maternity safety ambition to reduce the rate of stillbirths, neonatal and maternal deaths and brain injuries that occur during or soon after birth by 50% by 2025.
- HSIB has been running a continuous survey of NHS staff who have been interviewed for maternity investigations, to drive improvement in the programme. The figures for April 2020 to March 2021 demonstrate that 86.8% of staff who responded strongly agree that HSIB investigations will help to improve the safety of maternity care at their trust.
- In addition to the individual reports, we have provided to families and trusts, during the last year we have published four national learning reports. We worked in collaboration with the wider HSIB investigation team to highlight areas for national investigation.