What to expect from an HSIB maternity investigation
Every point of view is important and welcomed during an HSIB maternity investigation.
Our friendly and kind investigation team treats all members of NHS staff with the utmost respect, and we listen without judgement. You can find out more about what to expect by watching our video.
What we investigate
We investigate incidents that meet the Each Baby Counts, and MBRRACE-UK criteria.
Each Baby Counts is the Royal College of Obstetricians & Gynaecologists’ national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. MBRRACE-UK runs national Maternal, Newborn and Infant clinical Outcome Review Programme. You can find more information about our referral criteria on the what we investigate page.
Our maternity investigations have replaced the trusts' internal maternity serious incident investigations. We involve the trust and share the investigation reports as they are completed. Trusts continue to investigate maternity events that fall outside the specified criteria. Find out more about these criteria on the what we investigate page.
Trusts remain responsible for Duty of Candour, 72-hour report and reporting via the the Strategic Executive Information System (STEIS).
The incident should be reported to 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. Since 1 April 2020 HSIB have reported all potential eligible cases to NHS Resolution – Early Notification Scheme .
How we work with trusts
We make sure that trust staff are fully informed of the legal obligations we operate under and how this aligns with their professional responsibilities during investigations.
We also make sure that staff are supported throughout the investigation process. Our highly trained investigators ensure compassion and respect when we’re working together to build local and clinical knowledge during an investigation.
During our investigation trust staff may be asked for statements by the coroner.
Staff interviews help establish the facts about the incident.
Our interviews are based on open questions, although there will always be some more direct questions.
Our interview approach is not about finding or apportioning blame, nor is it the aim of our reports. We achieve this by describing what happened and how things can be done differently to prevent a repeat in the future. There is no blame or liability directed against individuals.
If staff are asked to attend an interview, they are welcome to bring a colleague with them (but not a family member or friend).
We obtain consent from staff before recording an interview.
We recognise that staff may be anxious about having their discussions recorded.
We understand that regional officers of the Royal College of Midwives (RCM) advise local stewards that audio recording of interviews is preferable. The medical defence unions (Medical Protection Society, Medical Defence Union and Medical and Dental Defence Union of Scotland) also recommend audio recording for interviews.
Feedback and reports
Investigators don't feed back to staff during the investigation. Once the report is produced it’s available for staff to read. We hope that the trust will provide a feedback and learning session for all staff.
We don't name individuals in our report, or give the grade of an individual, unless it’s relevant to understanding the circumstances of the incident.
We believe that through our investigative approach we will reduce the likelihood of unfounded concerns being raised about individuals, by explaining the circumstances of the incident and the role of any given individual in the process.
Information for trusts and staff
These documents help trusts to explain who we are and what we do, to the staff and families involved in maternity investigations.
If you would like to request any of these documents in another format, please email email@example.com. Other formats include easy read, large print, braille, or any other language or need.
Family card (PDF)
Information and security (PDF)
Family card in other languages
The family card is available to download in these languages: