Improving maternity care

The Maternity and Newborn Safety Investigation (MNSI) programme has published its annual report revealing the work it’s done to improve outcomes for women and babies. The organisation investigates deaths of babies and mothers as well as severe brain injuries suffered by newborns in England.

During 2023/24, it carried out 591 investigations and identified five main themes from the safety recommendations made to NHS trusts: clinical assessment, foetal monitoring, escalation, clinical oversight and risk assessment. It also developed a tool to improve how staff are approached following an incident, reflecting its practice of not placing blame on individuals.

The report said: “While the focus of an investigation should be on systems, processes and human factors, we know that healthcare staff will often blame themselves when a patient safety even occurs.

“Our role as the investigator is to ensure that we do not exacerbate this further in the way we ask questions, especially as this can often stay with staff long after our discussion has finished.

“However, by asking the right questions, we have the ability to take the focus away from the individual and show them that our real interest lies in the information that was available at the time, influencing human factors and the systems, processes and situation they were working with.”

The annual report also sets out MSNI’s ambitions for the future, including rolling out a new equality, diversity and inclusion toolkit and focusing on thematic learning.

MNSI Director Sandy Lewis added: “Our programme provides the opportunity to reflect on multiple aspects of the healthcare of women/birthing people and children, such as considering the impact of childbirth on long-term health or exploring the system factors that contribute to preterm birth. They also give us the chance to better understand the systems and processes that enable many women/birthing people and babies to have a positive experience of pregnancy, labour, birth and the postnatal period.”

Read the annual report