We recognise that this is a difficult time for you and those close to you.

All NHS trusts in England are required to tell us about certain patient safety incidents that happen in maternity care. This is so that we can carry out an independent investigation, share findings and make safety recommendations where relevant to improve maternity services. Our investigations are part of a national strategy to improve maternity safety. Throughout the investigation we work closely with the families, NHS trusts and trust staff involved.

The video below outlines the investigation process for families.

What we investigate

The patient safety incidents that are referred to us are babies born following labour after 37 weeks and where the outcome is:

  • Baby dies during labour and before birth (intrapartum stillbirth).
  • Baby born alive and dies in the first week (0-6 days) of life (early neonatal death).
  • Baby born with a potential severe brain injury diagnosed in the first 7 days of life.

We also investigate when mothers die whilst pregnant or within 42 days of the end of their pregnancy. There are some occasions where we do not investigate. You can find more detail about this on the ‘what we investigate’ page.

We review the safety issues identified across all individual investigations to look for recurring themes. This way we can also make safety recommendations to national organisations to improve maternity services across the whole healthcare system in England.

What we do

If you consent to participate in the investigation, we will:

  • Introduce you to a named investigator who keeps you updated throughout the investigation.
  • Ask you some questions to understand your individual needs and how we can best support them during the investigation. This may include advising you of other sources of support if you would like further help.
  • Involve you in the investigation into the care that was provided.
  • Encourage ongoing communication between you and the NHS trust during the investigation.
  • Look to identify areas for learning locally and nationally to improve maternity safety in the future.
  • Provide you with a report at the end of the investigation.

It’s important to understand that we:

  • Do not place blame on individuals or investigate individual members of NHS staff.
  • Do not carry out investigations from a legal or litigation perspective. This means we do not have direct contact with solicitors as part of our investigations. We respect the decision of families to seek legal advice about their case.
  • Cannot always answer all questions or concerns but will explain why.

What to expect

We ask you to tell us what has happened, so we have a full understanding of your experience. We understand it may be a difficult time and we’ll do all we can to support you and advise you of additional support you could access.

Our investigators do everything they can to put you at ease during the contact they have with you. They can be flexible about how, when and where to meet and try to make the contact work in a way that is right for you. For example, you might want to nominate another person to speak for you at times if you feel unable to do so yourself.

When the investigation is finished, we’ll share a final report with you. The report is anonymous and includes our findings, safety recommendations and safety prompts. It’s shared with you, the NHS trust and staff involved and any other appropriate organisations (for example, the local Integrated Care Board). We do not publish individual safety investigation reports.

Whilst telling us what has happened may be challenging, we want you to know that by sharing your experience you'll help us to see where safety improvements can be made for the benefit of others who use maternity services.

Dedicated point of contact

Our team is specially trained to work with families.

You’ll be given a named investigator as your dedicated point of contact along with how you can contact them or get a message to them.

Our team works Monday to Friday, 9am to 5pm and will try to respond to messages as quickly as possible during these times. If your named investigator is away for any reason, we’ll provide you with an alternative contact.

Your named investigator will keep you updated throughout the investigation.


Thorough safety investigations take time. Your investigation team will tell you how long they expect the investigation to take. This may change as the investigation progresses. If it does, your investigation team will explain why. We aim to complete all investigations within six months, but every investigation is different. It may take more or less time to complete your investigation.

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