Learning from our investigations

Our knowledge of the issues that we find recurring within individual trusts, and across multiple trusts, helps us to promote learning at a local and national level.

As we build this evidence, and identify persistent challenges, we have the opportunity to consider external evidence, including trust investigation reports, in thematic reports of maternity incidents within trusts.

We share findings, recommendations and general themes from all of our reports back to the trusts, to regional NHS local maternity systems and nationally. 

Improving safety as we investigate

We are developing various ways of feeding back to trusts throughout the investigation process. 

We share any concerning aspects of incidents with trusts at an early stage. We also share regular feedback on the progress of cases and a quarterly summary of the themes identified from all of the trust’s referred cases. We share investigation progress reports with the trust’s head of midwifery every 2 weeks.

Once we have completed a number of investigations within a single trust, we hold a workshop with that trust to understand the logistical impact of our work. 

We do this to: 

  • Minimise duplication and workload.
  • Develop feedback on common themes.
  • Raise actions that require immediate review to improve safety, in a quicker timeframe than waiting for our investigation reports to be completed.

We also develop stories to describe cases, which we share and use at learning events. They will be published here as we develop them. 

Implementing safety recommendations 

We work directly with trusts on an ongoing basis.

As incidents continue to be referred for HSIB investigations, we have sight of changes made. If the same recommendations are made again, this will be factored into our assessment of risk and subsequent safety recommendations to the trust. 

We have also agreed a memorandum of understanding between the Care Quality Commission and HSIB to set out how we share information for the purpose of improving patient safety. 

Working with other national maternity safety improvement programmes

In addition to families and trusts, we also share our completed investigation reports with regulators and professional bodies who can initiate change at a national level. This includes the Royal College of Obstetricians and Gynaecologists’ Each Baby Counts quality improvement programme, MBRRACE-UK and NHS Resolution

At present these organisations have different remits which means there is often some overlap between our investigations and the work undertaken in these programmes. For example, MBRRACE-UK has a wider remit than the Each Baby Counts programme as it considers perinatal mental health and late deaths. 

Information sharing is an important aspect of our contribution to maternity safety. We hope that our investigations, which are very detailed and thorough and closely involve the families, will have added learning and value to the work of other national maternity safety programmes. 

We will provide additional learning materials from our partnership working in this section.

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