A step-by-step guide to our maternity investigation process, for NHS trust staff involved in our investigations.


  • The NHS trust refers the case to the Maternity and Newborn Safety Investigations (MNSI) programme.
  • The NHS trust informs the family about MNSI and asks for their agreement to pass their contact details to us.

Acknowledgement of referral

  • MNSI phones the trust within one working day to acknowledge the referral.

Family contact by MNSI

  • MNSI contact the family within five working days (after the trust has informed the family about the referral and completed Duty of Candour, when required).
  • We obtain consent to access medical records, establish a communication approach, arrange an initial meeting and keep the family informed about investigation progress.

Information collection

  • The NHS trust collects information and uploads it to our secure investigation management system, known as HIMS.

Trust contact by MNSI

  • Agree terms of reference for the investigation and share with the trust and the family.
  • We interview the staff involved and work with you to identify immediate risks.
  • Trust staff are fully informed of the legal obligations we operate under and how this aligns with their professional responsibilities during investigations.
  • Our highly trained investigators are compassionate and respectful when we’re working together to build local and clinical knowledge during an investigation. We also check that the wellbeing of staff is considered throughout the investigation process by asking that trusts support them as needed and by telling them about other relevant agencies who can provide support.

SMART review

  • Information provided by the trust and gathered by the investigation is considered by a MNSI subject matter advisor review team (SMART) review.
  • Subject matter advisors are experienced clinicians from relevant medical specialities within the NHS.
  • The review provides professional opinion on the information, interpretation of clinical evidence which is supported by national guidance and identifies further lines of enquiry that may be necessary.
  • There may be a number of SMART reviews during an investigation.


  • Investigators analyse findings.
  • Clinical advice is sought to progress the investigation.
  • Investigators keep you updated on the progress of the investigation.

Draft report

  • A draft report is prepared detailing what happened, any findings and safety recommendations.
  • The draft report goes through a comprehensive quality assurance process.
  • The draft report is shared with the trust and the family. We can discuss any details that you believe have been written inaccurately.

Final report

  • We give the final report to the trust and the family.
  • MNSI talk to the family about the opportunity to hold a three-way meeting between the trust, MNSI and the family to discuss any next steps (we call this the tripartite meeting). This is led by the trust.
  • It is the trust’s responsibility to share the report with the local integrated care board (ICB).
  • The report may also be shared with the coroner if requested.
  • The investigation concludes.


  • We ask staff involved in the investigation to feedback and tell us about their experience of our maternity investigation process, so that we can continuously improve it.
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