Latest news
MNSI Response to HSSIB’s Review of Maternity and Neonatal Services
The Health Services Safety Investigations Body (HSSIB) has published their review of maternity and neonatal services.
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Safety Spotlight: Neonatal Exchange Blood Transfusion
A baby received an exchange blood transfusion. This is a specialist and complex procedure with associated risks (and is now infrequently performed in most neonatal units).
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MNSI attends Five X More Black Maternity Experiences Report
Five X More’s Black Maternity Experiences Report 2025 was published on Monday 21 July. The report captures the lived experience of over 1,164 Black women who have been pregnant or have given birth in…
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Safety Spotlight: Deaths from Anaphylaxis
MNSI responds to Dash review of patient safety across the health and care landscape
Responding to the second part of the independent Dash review of patient safety across the health and care landscape
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MNSI responds to the publication of the NHS 10 Year Plan
In response to the publication of the 10 Year Health Plan, which is part of the government’s mission to build a health service fit for the future, Sandy Lewis, Director of The Maternity and Newborn S…
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MNSI responds to maternity and newborn safety announcement 23 June 2025
A response to yesterday's announcement on maternity and newborn safety by The Rt Hon Wes Streeting, Secretary of State for Health and Social Care , from Sandy Lewis, Director of The Maternity an…
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WEBINAR SERIES 2: Exploring learnings from MNSI safety investigations
We are starting a new series of webinars in 2025 which will explore learnings and thematic analysis from our safety investigations.
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Safety Spotlight: Investigations into equipment and technology used for continuous fetal heart rate monitoring
MNSI has completed Investigations into equipment and technology used for continuous fetal heart rate monitoring.
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Shaping the future of MNSI: a new three year strategy
MNSI response to Sands Fetal Movement Report 12 May 2025
We welcome the publication of Sands' "Improving information and guidance about fetal movements: a horizon scanning project" report. This important work aligns closely with key themes w…
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MNSI pilots COMPASS - a new patient safety tool
COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is a new patient safety tool to help understand the impact of organisational culture on patient safety and is currently being tri…
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Safety Spotlight: Delayed escalation in abnormal CTGs
MNSI has completed a number of investigations in which time limits, as described in national guidance, have delayed categorisation of CTG recordings, resulting in delays in escalation.
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Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety
COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is a tool developed by MNSI to provide a standardised process for our staff to articulate, analyse, and feedback observations abo…
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Safety Spotlight: Prescribing and dispensing of low molecular weight heparin
Things MNSI recommend considering when prescribing low molecular weight heparin to avoid incorrect doses being dispensed.
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WEBINAR SERIES 1: Catch up with previous webinars
Catch up with our series of webinars, which explore learnings and thematic analysis from our safety investigations.
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Safety Spotlight: Incomplete observations generating incorrect EWS
MNSI has investigated a number of patient safety events where an incomplete set of observations generated an early warning score (EWS) via an electronic patient record (EPR) system.
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Safety Spotlight: Changes to the MNSI investigation report template
On 1st April 2024, six months after the transition to being hosted by the CQC, MNSI changed their investigation reports and process.
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Safety Spotlight: Maternal Deaths in the first trimester from Venous Thromboembolism (VTE)
MNSI has undertaken investigations of maternal deaths in the first trimester from venous thromboembolism (VTE)
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Safety Spotlight: Patient Ethnicity Data Collection
MNSI has found that inaccurate or missing recordings of a woman’s ethnicity have impacted her subsequent pathway of care.
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Meet our Clinical Fellows
In September we welcomed two clinical fellows to support our work to improve maternity safety in England.Our clinical fellows have been supporting a number of projects designed to analyse thematic fi…
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MNSI referral of babies receiving therapeutic cooling as part of the COMET trial
The National Institute for Health and Care Research (NIHR) has recently funded the COMET trial, which is designed to evaluate the safety and efficacy of induced cooling in babies with mild encephalop…
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MNSI responds to the CQC 2024 National Maternity Survey
The Maternity and Newborn Safety Investigation (MNSI) programme has responded to the latest annual national maternity survey by the Care Quality Commission (CQC).
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The Maternity and Newborn Safety Investigation (MNSI) programme publishes it’s 2023/ 24 annual report
The report provides an overview of the work of the MNSI programme during 2023/24. It sets out the activities carried out by the investigation team since October 2023 when it transitioned to be hosted…
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MNSI Annual report 2023/24 published
MNSI’s Annual Report 2023/24 shines a light on the work MNSI has undertaken in 2023/24 and shares the programme’s ambitions for 2025 and beyond.
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The Maternity and Newborn Safety Investigation programme response to The Care Quality Commission (CQC) State of Care 2024 report.
Katherine Hawes, Deputy Director (Investigations) of the Maternity and Newborn Safety Investigation Programme, said:
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Commenting on the announcement of the Dash review into patient safety
Commenting on the announcement of the Dash review into patient safety, Sandy Lewis, Maternity and Newborn Safety Investigation Programme Director said:
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An open letter to parents and families this Baby Loss Awareness Week
The 9 – 15 October each year marks Baby Loss Awareness Week (BLAW). We know from speaking to the parents and families who are part of our work that it is a week filled with mixed emotions; sadness th…
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MNSI responds to the National Maternity Inspection Report
The Maternity and Newborn Safety Investigations programme (MNSI) welcomes today’s publication of the National Maternity Inspection Report.
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Our Ambitions for 2024 – Part Two
Director of the Maternity and Newborn Safety Investigation Programme, Sandy Lewis outlines MNSI’s ambitions for the final five months of 2024 as the team continues their work to improve maternity saf…
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MNSI responds to report by the All-Party Parliamentary Group on Birth Trauma
The Maternity and Newborn Safety Investigations programme (MNSI) welcomes today’s publication and recommendations that call for safe staffing levels, mandatory training on trauma-informed care and un…
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National learning report highlights key factors needed to ensure safe care in midwifery units
MNSI has today published a report identifying the main factors affecting the delivery of safe care in NHS hospital midwifery units.
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Changes to the MNSI investigation report template
On April 1st 2024, six months after the transition to being hosted by the CQC, MNSI made changes to their investigation reports and process. Zoë Munson, a maternity investigator, and co-chair of the …
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Inspiring inclusion and empowering MNSI investigators
The theme for this year’s International Women's Day (8 March) is ‘inspire inclusion’, so it's timely to reflect on the steps we’re taking to inspire inclusivity within our investigative pra…
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Why it made sense at the time: Local rationality questions for healthcare investigations
Louise Roe explains how she developed an interview framework that safeguards interviewees and deepens local rationality questioning
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MNSI Ambitions for 2024
With MNSI’s transition to CQC completed and a new year underway, it’s a good time to look towards the year ahead and a new chapter in MNSI’s history. Sandy Lewis, Director of the Maternity Investigat…
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Safety factors surrounding effective communication throughout the pregnancy journey
In this blog, MNSI highlights the safety factors that work well, identifies where there are barriers to effective communication and recognises the work that is taking place to overcome them.
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Maternity Investigation Programme Year in Review 2022/23
During 2022/23 the maternity programme completed 702 reports and made more than 1,380 safety recommendations, with families remaining central to the work we undertake.
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Issues with access to public defibrillators
Sharon Perkins, Maternity Investigator, takes a closer look at the use of community public access defibrillators, often known as (CPADs).
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International Day of the Midwife 2025
Midwives have a critically important role in the safety of women / birthing people, and their babies. In celebration of International Day of the Midwife 2025, Katherine Hawes, Deputy Director at the …
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International Day of the Midwife 2023
This blog post was published when our programme was part of the Healthcare Safety Investigation Branch (HSIB). Find out about HSIB legacy.
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Understanding the doula’s role in maternity safety investigations
In this blog, we review doula involvement in maternity cases referred to us for safety investigations.
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Maternity investigations programme to be hosted by Care Quality Commission
It has been announced via a Written Ministerial Statement that the Healthcare Safety Investigation Branch’s (HSIB’s) maternity programme will be hosted later this year by the Care Quality Commission …
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Risk assessments during the maternity care pathway
Following the publication of our national learning report on the same topic, Sonia Barnfield looks at risk assessments during the maternity care pathway.
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National learning report highlights risks associated with ‘incomplete’ maternal risk assessments
Our latest learning report emphasises that maternity risk assessments can be inconsistent and do not support changes in pregnant women/person’s circumstances during the ‘maternity pathway’ (pregnancy…
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