MNSI Annual Report and Recommendations 2024/25

The Maternity and Newborn Safety Investigations (MNSI) programme has today published its Annual Report 2024/25, highlighting a year of activity aimed at improving safety for women, babies, and families across England.

Between April 2024 and March 2025, MNSI completed 613 investigations and made 1,122 safety recommendations to 126 healthcare organisations.

The most frequent themes in the recommendations made by MNSI for 2024/25 related to:

• clinical assessment
• escalation
• guidance
• clinical oversight
• communication

Sandy Lewis, Director of the MNSI programme, said: “Our Annual Report 2024/25 reflects both the volume of work completed this year and the steps we are taking to strengthen how learning is shared.

“With over 600 investigations and more than 1,100 safety recommendations, the focus now is on making that insight more accessible and useful for NHS trusts and families. Developments such as clearer reports, safety prompts, and the integration of equity tools are helping us to support consistent improvements in maternity and newborn safety across England.”

The report also highlights improvements and innovations in how MNSI shares learning, including:

• A new report style designed to be clearer for families and trusts.
• Introduction of safety prompts, giving trusts practical questions to improve local practice.
• Pilot and development of the COMPASS tool to capture cultural issues influencing safety.
• Embedding of health equity tools (HEART and HEWS) into all new investigations to ensure inequalities are systematically addressed.

Louise Page, Clinical Director at MNSI, added: “This year we have continued to see how investigations can highlight the challenges faced by NHS maternity and neonatal staff, and how practical recommendations can support safer care. Alongside this, the introduction of tools such as COMPASS and HEART and HEWS is helping us better understand the wider influences on safety. By combining detailed investigations with these broader approaches, we are building a more rounded picture of how improvements can be made.”

The Annual Report also shows strong engagement from healthcare staff and families. 95% of trust staff said MNSI’s investigation process was clear, while 86% agreed the programme is improving safety and culture. Families described feeling listened to and valued, with many reporting that MNSI’s investigations gave them answers and reassurance they would not have otherwise received.

MNSI will build on this work in 2025/26, expanding its thematic learning through new coding systems and AI-supported analysis, while continuing to share learning nationally and internationally.

The full MNSI Annual Report 2024/25 is available at the link here.

A complete list of the safety recommendations, is available at the link here.