National strategy

The National Maternity Safety Ambition, launched in November 2015, aims to halve the rates of stillbirths, neonatal and maternal deaths, and brain injuries that occur soon after birth, by 2025. This strategy was updated in November 2017 with a new national action plan called Safer Maternity Care. This sets out additional measures to improve the rigour and quality of investigations into term stillbirths, serious brain injuries to babies and deaths of mothers and babies.

The Secretary of State for Health and Social Care asked us to carry out the work around maternity safety investigations outlined in the Safer Maternity Care action plan. Our work started in April 2018, and we achieved full national coverage in April 2019.

Our programme was part of the Healthcare Safety Investigation Branch (HSIB) until September 2023. As of October 2023, we are known as the Maternity and Newborn Safety Investigations (MNSI) programme and are hosted by the Care Quality Commission (CQC).


Our new Directions have been published by the Department of Health and Social Care (DHSC). These directions require the Care Quality Commission to exercise the functions set out from 1 October 2023.

CQC hosting arrangement

As of 1 October 2023, the Maternity and Newborn Safety Investigations (MNSI) programme is hosted by CQC.

The arrangement with CQC ensures the continuation of the maternity programme and will maintain the independence of maternity investigations within the NHS. We have published information on how we share concerns with CQC.

The purpose of MNSI remains the same: 

  • to provide independent, standardised and family focused investigations of maternity cases for families;
  • to provide learning to the health system via reports at local, regional and national level;
  • to analyse data to identify key trends and provide system wide learning; be a system expert in standards for maternity investigations;
  • and to collaborate with system partners to escalate safety concerns.
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