From today, all trusts in England will be referring maternity cases to HSIB

From 1 April 2018, we became responsible for the investigations of maternity incidents that met the criteria for the Each Baby Counts programme. The first team of six maternity investigators started training in April 2018 and the first trusts started referring cases in May 2018.

Programme progress 

We have now recruited and trained over 140 investigators and team leaders, clinical advisors and specialist advisors to help scope investigations, analyse findings and form safety recommendations. By the end of March, it is estimated that there will be 400 live cases, with around three new referrals coming in every day. 

Professor Jimmy Walker, Clinical Director of Maternity Investigations said: “The rollout of the maternity investigation programme across so many trusts has been an ambitious and exciting challenge which we are proud to have delivered. It has been possible due to the dedication and hard work of our teams, as well as fantastic support from trusts, staff and the families.

“We are beginning to see, understand and develop some of the main themes that will help us to prevent a recurrence. The responses to our reports and feedback have been positive and we are already seeing signs of beneficial change. 

“The year ahead will enable us to stabilise the programme and start drawing out the key areas of learning whilst understanding how we can share this back across the NHS and influence the care families receive.” 

Family engagement 

A key highlight of the programme has been our innovative family engagement model, with investigators working closely with HSIB’s expert lead in the area, Louise Pye. As a result, over 97% of families have agreed to be involved in the investigations.

Sandy Lewis, Director of Maternity Investigations commented: “Working effectively with the families involved has been a huge priority for us. We are very grateful to the families who have allowed us into their lives at such a difficult time and with whose consent we are able to function. We also thank trusts and their staff, who have been positive and engaged throughout investigations.”  

For maternity incidents, our investigation replaces the local investigation, although the trust remains responsible for Duty of Candour and for referring the incident. The reports and safety recommendations are sent directly to the families and the trust.

Find out more in our maternity investigations section