MNSI Annual Report and Recommendations 2025/26

Today we have published our Annual Report 2025/26, which highlights a year of activity aimed at improving maternity and newborn safety for women, babies, and families across England.

Between April 2025 and March 2026, MNSI completed 618 investigations and made more than 1,300 safety recommendations.

The most frequent themes in the recommendations made by MNSI for 2025/26 related to:

clinical assessment
guidance
fetal monitoring
communication
escalation

Over the last year MNSI has continued to develop the work it undertakes with families, trusts and NHS staff to make maternity and newborn care in England safer.
I would like to thank families for sharing their experiences, trusts for working with us to implement learning, and NHS staff for your openness to meaningfully implement safe care.

— Sandy Lewis, Programme Director

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

launch of MNSI’s two-year programme strategy (2025-27), sharpening its focus on prevention and partnership.
development of the SPARC coding framework, enabling deeper thematic analysis of investigation findings.
expansion of the COMPASS pilot, now running across 29 NHS trusts, to capture how organisational culture affects safety.
continued use of health equity tools (HEART and HEWS), which explored inequalities in 100% of maternal death investigations.

Through safety recommendations, safety prompts and thematic outputs, this report demonstrates how learning is applied in practice – supporting services to strengthen clinical processes, improve consistency and deliver safer care. This reflects our commitment to collaboration, integrity, excellence and learning and to ensuring that insight leads to sustained improvement.

— Louise Page, Clinical Director

The Annual Report also shows strong engagement from healthcare staff and families. 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 continue to build on this work in 2026/27.

Annual report 2025/26

Annual recommendations 2025/26