MNSI recognises HM Coroners as important external stakeholders and is committed to cooperating with and assisting coronial investigations and inquests as far as possible.
Here, we set out our approach to working with HM Coroners, while meeting our role and purpose and respecting the confidential nature of the material we gather and produce.
The MNSI programme role
The 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 our investigations, MNSI uses information gathered from various sources, including interviews and/or confidential statements from staff and/or family, to gain an overall view of an event. We share all the key 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.
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 programme, we must therefore encourage as candid a view of events as possible to extract points of learning. To do so, it is imperative we maintain as safe an environment as possible for staff to discuss how and why they believe things did not go as planned. Our experience is that interviews conducted in confidence, where staff have been able to be open with facts and 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. This means we must establish and maintain staff trust in MNSI that the confidentiality of their personal information will be protected.
MNSI investigation reports
The MNSI investigator is responsible for ensuring that all relevant information is captured in the final report and sharing the 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, to the CQC and other national healthcare bodies.
We do not publish the final investigation reports – in order to protect the family involved and the staff/trust and where details of an event with unusual patterns/ circumstances may make identification of an individual more likely.
A Maternity Investigator will inform HM Coroner that we are conducting an investigation and HM Coroner can ask that we share a copy of the report on conclusion of our investigation. Our standard practice is not to share a draft report as these reports follow a factual accuracy process and remain subject to change until the Trust and family have reviewed, and the report has been finalised.
Working with HM Coroners
For the reasons outlined above, it is our position that disclosure of the final MNSI investigation report is generally sufficient for disclosure purposes. 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
- undermining the integrity and effectiveness of MNSI, and public trust in MNSI as an independent safety investigation programme.
In those circumstances, where HM Coroners:
- Request disclosure of a copy of the final MNSI investigation report:
- MNSI will provide a copy of the final investigation report
- Request disclosure of additional material gathered by MNSI as part of our investigation to inform the report, including, for example, staff statements or interview notes:
- MNSI will ask that the request is made by way of a schedule 5 disclosure notice requiring disclosure or production.
- Receive disclosure from MNSI:
- That material should be treated as first stage disclosure to HM 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).
- Where HM Coroner considers onward, second-stage disclosure of the MNSI material to other interested persons, they should not do so without first inviting representations from MNSI, in line with paragraph 14, Chapter 12 of the Chief Coroner’s Guidance for Coroners on the Bench and Chief Coroner’s Law Sheet No 3 (PDF).
- MNSI will set out in a covering letter accompanying the disclosure a summary of MNSI’s role and purpose, the sensitive and/or confidential nature of the material it gathers and produces. The approach MNSI takes in this being treated as first stage disclosure to HM Coroner alone; and the importance of MNSI being given the opportunity to make representations prior to onward disclosure if HM Coroner is considering this.