Earlier this year, the Healthcare Safety Investigation Branch (HSIB) published the summary of their findings from their maternity investigation programme.
The report makes for an interesting read and highlights some key themes and issues found during the last year and after the serious issues in maternity services which have come to light over the last few years, it is important to consider where the problems lie and how improvements can be made. Let’s have a look at this in more detail.
What is the maternity and newborn safety investigation?
The programme of investigations into maternity and newborn safety incidents began in 2018 as part of a national initiative to improve safety in maternity care.
All NHS Trusts are required to tell the Maternity and Newborn Safety Investigation MNSI about certain patient safety incidents that happen in maternity care so that an independent investigation can be carried out and, where relevant, safety recommendations can be made to improve services.
The purpose of the programme is:
- To provide independent, standardised, and family-focused investigations of maternity cases for families.
- To provide learning to the health system through reports at local, regional, and national levels.
- To analyse data to identify key trends and provide system-wide learning.
- To be a system expert in standards for maternity investigations.
- To collaborate with system partners to escalate safety concerns.
2022/23 findings
The report of last year’s findings shows that there were 1,070 referrals to the programme. Of those, 399 did not progress to an investigation. HSIB completed 702 reports over the course of the year. Of the referrals which progressed to an investigation:
- 9% related to maternal deaths.
- 13% related to neonatal deaths.
- 26% related to intrapartum stillbirths.
- 52% related to babies diagnosed with brain injuries or cooled babies.
Some of the key highlights found in the report were:
- The number of investigation referrals relating to brain injury indicates a sustained decrease in babies with abnormal MRI results or neurological damage.
- In the last year, the programme made more than 1,380 safety recommendations to trusts and other healthcare providers.
- Their reports have identified racial differences in maternity outcomes.
- The programme has helped to increase the involvement of perinatal teams in patient safety.
- The programme has deepened the understanding of the role of emerging themes and how they help to identify issues in the healthcare system as a whole that contribute to the harm experienced by pregnant women/people and their families.
Emerging themes
The HSIB’s findings over 2022/23 identified the following themes from safety recommendations made to trusts during the year:
- Clinical assessment
- Guidance
- Fetal monitoring
- Clinical oversight
- Risk assessment
- Escalation
- Communication
- Investigations
- Clinical observations
- Induction of labour
- Information
- Triage
As a result, the HSIB has been working to discover the interaction between these themes and their interdependence in their actions and effects. This is all part of understanding that if one area is deficient, it will affect others and that looking into this in more detail will help in designing systemic improvements which will ultimately improve patient safety.
Changes ahead
It was announced earlier this year that the Maternity and Newborn Safety Investigation (MNSI) programme will be hosted by the Care Quality Commission going forward. That change comes into force this month, rather than the HSIB.
Why is the CQC now hosting the programme?
The new hosting arrangements come into force as the HSIB becomes a Non-Departmental Public Body, called the Health Services Safety Investigations Body.
The CQC says that this new arrangement will enable high-quality, independent, family-focused maternity investigations to continue. It will also ensure that the MNSI programme:
- Maintains the independence of maternity investigations within the NHS.
- Has the opportunity for further collaboration within the health and social care sector.
- Is able to access more resources as part of a larger organisation, including improved analytics capacity and the opportunity to contribute best practice learning through national reporting.
Comment
Following recent tumultuous years in maternity services across the country, it is important for the public to see proactive approaches being taken to make improvements.
For too long, patient safety for mothers, babies, and families utilising maternity services, has been put at risk. The MNSI will continue to play a key part in identifying the issues and working on the resolutions to those, so it is pleasing to see that the CQC is now stepping in to host the programme, ensuring not only that it can continue, but that it also maintains a quality and independence which is so vital to these issues.
How can we help?
Danielle Young is a Legal Director in our Medical Negligence team, which is ranked in Tier One by the independently researched publication, The Legal 500.
If you have any questions about the subjects discussed in this article, please contact Danielle or another team member in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online form.
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