The way we work and report on maternity investigations is different to our national investigations. Find out more below about what we publish as part of our maternity investigation programme.
Maternity investigation reports
Individual maternity investigation reports are shared with the family, the trust and the healthcare professionals who were involved in the incident. Unlike our national investigation reports, we don’t publish individual maternity investigation reports.
Our maternity investigation reports include the terms of reference for the investigation, the process of investigation, the evidence and safety recommendations for improvement at an organisational and national level.
Due to higher than expected referral numbers and the phased rolling out of the programme across the country, our initial reports are taking longer than we had anticipated to reach conclusion. All families and trusts are being kept fully informed at every stage of an investigation’s progress. All stakeholders are aware of our process and trusts will not be penalised by regulators for any perceived delays resulting from HSIB maternity investigations.
Our aim is to complete the full investigation process within six months, but some complex cases take longer. Our investigation process is becoming more efficient as we learn and adapt. From April 2019 we expect that all but the most complex investigations will be concluded within six months.
National learning reports
We publish national learning reports that describe common themes and findings that arise from both our national investigations programme and maternity investigations programme. We use the information from these national learning reports to inform future HSIB investigations.
Our maternity national learning reports:
- Summary of themes arising from the HSIB maternity programme.
- Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection.
- Neonatal collapse alongside skin-to-skin contact.
- Maternal death national learning report.
- Severe brain injury, early neonatal death and intrapartum still birth associated with larger babies and shoulder dystocia
HSIB Maternity Quarterly Newsletter
Our quarterly newsletters share learning from trusts across the whole of England. The newsletter allows clinical teams and trusts to share the changes that have been made as a result of our findings and safety recommendations from our maternity investigations undertaken.
East Kent Hospitals summary report
In January 2020 we were asked by the Department of Health and Social Care to provide a summary report of all the investigations we had undertaken, up to that point, with East Kent Hospitals University NHS Foundation Trust (EKHUFT). This was due to rising concerns around the care provided by EKHUFT’s maternity services at William Harvey Hospital in Ashford and the Queen Elizabeth the Queen Mother Hospital in Margate.
The summary report provides an overview of:
- the referrals caseload under the maternity investigations programme for EKHUFT
- the themes which were identified as indicative of patient safety risk to mothers and babies
- the engagement and escalation process that HSIB undertook with the Trust and the wider system in response.