MNSI Position Statement regarding cooperation with Coroners and disclosure to Coroners

MNSI recognises Coroners as important external stakeholders and is committed to cooperating with and assisting coronial investigations and inquests as far as possible.

The nature of MNSI’s role and purpose, the sensitive and/or confidential nature of the material it gathers and produces, and the approach MNSI takes in doing so is such that MNSI adopts a general position statement in relation to requests and requirements from coroners for MNSI investigation reports and/or information gathered by MNSI during its investigations to inform those reports. We summarise those on this page to provide reasoning for that general position statement.

The role of the Maternity and Newborn Safety Investigation (MNSI) programme

MNSI programme forms part of a national strategy to improve maternity safety across the NHS in England. Since 1 October 2023 it has been hosted by the Care Quality Commission (CQC).

MNSI undertakes independent maternity safety investigations that fall within one of the categories set out in the Care Quality Commission (Maternity and Newborn Safety Investigation programme) Directions 2023. The MNSI programme is dedicated to undertaking thorough and impartial investigations, and to ensuring that our findings reflect the highest standards of clinical accuracy, objectivity, and expert insight.

As part of its investigations, MNSI uses information gathered from various sources, including, but not limited to interviews and/or or confidential statements from staff and/or family, to gain an overall view of an event. We then share all the pertinent facts with the family and the trust/staff in a final report, adopting a no-blame approach focussed on assisting with future learning and attempting to reduce the risk of repetition of any learning identified.

A crucial element of evidence gathering in our investigations involves offering hospital/trust staff the opportunity to be interviewed, to provide statements and/or to answer questions in confidence. MNSI does not have statutory powers to require staff or family to be interviewed or to provide statements. As an independent safety investigation body MNSI must therefore encourage as candid a view of events as possible to extract points of learning. To do so, it is imperative MNSI maintains as safe an environment as possible for staff to discuss how and why they believe things went wrong. MNSI’s experience is that interviews conducted in confidence, where staff have been able to be open and forthcoming with facts as well as give their own opinions, are far more likely to reveal underlying systemic reasons leading to patient harm. MNSI investigations are not able to rely on statutory Safe Space provisions either. This means that MNSI must establish and maintain staff trust in MNSI that it will ensure where possible that the confidentiality of their personal information will be protected.

MNSI Investigation reports

The relevant MNSI investigator is responsible for ensuring that all relevant information is captured in the final report and share the completed report with the mother/family and the trust/staff engaged in the provision of care. There is no requirement on MNSI to disclose any additional investigation documents to the family or Trust. Where appropriate and necessary, we may also raise concerns identified by our investigations more widely, not just to the wider CQC but also, with other relevant national bodies responsible for healthcare. However, MNSI does not publish the final investigation reports. This is to ensure we protect the family involved and the staff/trust as much as possible and to prevent copies of reports being obtained, where details of an incident with unusual patterns/circumstances may make identification of an individual more likely.

This approach ensures MNSI can provide a comprehensive report to families, as well as give confidentiality assurances to staff working within healthcare environments within the limitations of respective legal rights and obligations.

General position

For the reasons outlined above, it is MNSI’s position that disclosure of the final MNSI investigation report is generally sufficient for disclosure purposes; and that onward sharing of additional sensitive and/or confidential information gathered to inform that report, including interview recordings or staff statements, can give rise to significant risks of

• undermining staff trust in MNSI;
• reducing willingness of Trust staff to provide relevant information to MNSI at all and/or with candour; and
• ultimately undermining the integrity and effectiveness of MNSI, and public trust in MNSI as an independent safety investigation programme.

In those circumstances, where Coroners:

1. Request disclosure of a copy of the final MNSI investigation report MNSI investigation report: 
   1. MNSI will provide a copy of the final investigation report
2. Request disclosure of additional material gathered by MNSI as part of its investigation to inform its final investigation report, including for example staff statements or interview notes:
   1. MNSI will request that the request is made by way of Schedule 5 disclosure notice requiring disclosure or production etc
3. Receive disclosure from MNSI:
   1. that disclosure material should be treated as first stage disclosure to the Coroner alone in line with the two-stage disclosure process set out in the Worcestershire cases (Worcestershire CC v Worcestershire LCSB and HM Coroner Worcestershire [2013] EWHC 1711, [2013] Inquest Law Reports 179);
   2. Where the Coroner considers onward, second-stage disclosure of the MNSI material to other interested persons they should do not do so without first inviting representations from MNSI, in line with paragraph 14, Chapter 12 of the Coroner’s Bench Book and Chief Coroner’s Law Sheet No 3 (PDF); and
   3. MNSI will set out in the covering letter accompanying disclosure a summary of the nature of MNSI’s role and purpose, the sensitive and/or confidential nature of the material it gathers and produces, and the approach MNSI takes in doing so as reasoning for the importance  of both the disclosure being treated as first stage disclosure to the coroner alone; and the importance of MNSI being given the opportunity to make representations prior to onward disclosure wherever the Coroner is considering to do so.