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Maternity investigations

Working with families and NHS trusts to improve maternity care and bring about lasting change across the NHS.

Making maternity care safer

Our maternity investigation programme is part of a national action plan to make maternity care safer. We undertake approximately 1,000 independent maternity safety investigations a year to identify common themes and influence systemic change.

We have been tasked with carrying out these maternity investigations because we are in a unique position as a national and independent investigating body to:

  • Use a standardised approach to maternity investigations without attributing blame or liability.
  • Work with families to make sure we understand from their perspective what has happened when an incident has occurred.
  • Work with NHS staff and support local trust teams to improve maternity safety investigations.
  • Bring together the findings of our reports to identify themes and influence change across the national maternity healthcare system.

All NHS trusts with maternity services in England refer incidents to our team.

HSIB Maternity programme year in review 2020/21

The maternity programme review reflects the work undertaken in 2020/21. The importance of adapting our work with families, staff and trusts to provide opportunities for learning at local, regional and national level has remained a priority during unprecedented times within the NHS. As an organisation we continue to develop our approach to ensure those we work with remain central to our work.

"We were included, respected and cared for throughout the process. It allowed us to start finding some peace. Other organisations have a huge amount to learn from the way HSIB engages with families." - Maternity investigation feedback, 2020

An older woman gives a younger woman a hug.

Background 

The National Maternity Safety Ambition - launched in November 2015 - aims to halve the rates of stillbirths, neonatal and maternal deaths, and brain injuries that occur soon after birth, by 2025. This strategy was updated in November 2017 with a new national action plan called Safer Maternity Care, which set out additional measures to improve the rigour and quality of investigations into term stillbirths, serious brain injuries to babies and deaths of mothers and babies. 

The Secretary of State for Health asked HSIB to carry out the work around maternity safety investigations outlined in the Safer Maternity Care action plan. Soon after the action plan was announced our implementation team developed our approach and investigation methodology, and started to recruit maternity investigation teams.

Directions were tabled in parliament to give HSIB the remit to conduct the maternity investigations programme. Our work started in April 2018 and we achieved full national coverage in April 2019.