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 NHS trusts, trust staff and families involved.

The video below outlines the investigation process for NHS staff.

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 regularly 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 NHS trusts do

Referrals from all NHS trusts are made using our investigation management system, known as HIMS. Find out how to refer a case to us and the investigation process for NHS trusts.

A key part of our information collection is to interview the staff involved in providing care, or who witnessed anything that could be relevant to the investigation.

At the end of the investigation, we share a report with the trust. The trust is responsible for implementing any safety recommendations made in the report.

What we do

As part of the investigation, we will:

  • Introduce you to a named investigator who keeps you updated throughout the investigation.
  • Work in partnership with the trust to understand the clinical environment, explore staff perception of events, review patient notes and consider all other relevant information.
  • Encourage ongoing communication between the trust and the family.
  • 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, NHS trusts and staff to seek legal advice about their case.
  • Cannot always answer all questions or concerns but will explain why.

Dedicated point of contact

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.

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