Investigation process

Our maternity 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 important to us.

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.

What the trust does

Complete the referral

  • Make the referral and upload the case note to the secure HSIB Investigation Management System (HIMS).
  • All referrals should be reported as a serious incident (SI). The trust remains responsible for reporting the incident within 72 hours via the Strategic Executive Information System – the database where serious incidents are reported and monitored (this is a national requirement).
  • Incidents involving babies with a potential severe brain injury, where there is clinical or MRI evidence of neurological injury, should be reported to the NHS Resolution (NHSR) Early Notification (EN) Scheme, quoting the HSIB reference.
  • 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.

Inform the family

  • When a case meets criteria for referral, inform the family and provide further information about us, including the HSIB family card.
  • Complete duty of candour.

Gather evidence

  • Scan all relevant notes relating to the case and upload to HIMS.
  • Identify and support trust staff involved in the case.
  • Provide staff with information about us, including the staff information leaflet.

What HSIB does

Acknowledge receipt of the referral

  • Phone the trust within one working day.
  • Provide the trust with further information they need about the family for the investigation.

Contact the family

  • Contact the family within five working days. This happens after the trust has informed the family about the referral and where required, completed Duty of Candour.
  • Get verbal consent and establish a communication approach.
  • Arrange an initial meeting at an agreed location.
  • Keep the family informed of the investigation's progress.

Trust visits

  • We will visit trusts a number of times during an investigation.
  • Review notes and evidence.
  • Meet and interview the staff involved.
  • Work with the trust to identify immediate risks.
  • Subject matter advisor review team (SMART) review.
  • Agree terms of reference for the investigation and send to the family and the trust.

Analyse evidence

  • Identify any gaps in the evidence.
  • Consider findings and potential safety recommendations.
  • Organise second SMART review.
  • Keep the trust informed of the investigation's progress.

Quality assurance

  • Draft report is reviewed at report panel. Report panels may be attended by relevant clinical subject matter advisors who provide advice and guidance to the investigation team.
  • Draft report is shared with trust and staff involved to check for factual accuracy.
  • Draft report is shared with the family to check for factual accuracy.

Final report

  • Final report shared with the family.
  • Final report shared with the trust, NHS Resolution and other appropriate organisations. It is the trust's responsibility to share the report with the local clinical commissioning group (CCG).