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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 is aware of maternal deaths from anaphylaxis.
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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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MNSI Exploring learning webinars (1)

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

Work has begun to develop a new three-year strategy for MNSI.
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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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MNSI Exploring learning webinars (1)

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

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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Interview

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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Pregnancy consultation

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 year in review cover 2022-23

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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Public defibrillator

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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Midwife with woman in labour

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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Doula gives back massage

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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Houses of Parliament

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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Pregnancy bump

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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Antenatal appointment

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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