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 trialled across 12 trusts. The tool has been developed by Chris McQuitty (Clinical Fellow) and Nicki Pusey (Maternity Investigation Team Leader) to provide a standardised process for MNSI staff to articulate, analyse and feedback observations about organisational safety culture.

It is based on work carried out by the Patient Experience Library who conducted a literature review of avoidable harm enquiries over 10 years, which included the reports on the maternity services at East Kent and Morecambe Bay. The work had been collated into a report called ‘Responding to Challenge’ which was published last week.

Commenting on the report and the new COMPASS tool, Sandy Lewis, Director of MNSI, said:

“The report highlights the importance of an organisation’s culture towards patient safety. The response towards families and staff following a safety event can provide an indication of a systemic issue and reflects what we can see within our safety investigations.

“These issues can be subtle and difficult to describe. Within maternity and newborn services, they can have a significant impact and result in repetitive events occurring. Trusts that have a positive culture to patient safety and learning are able to demonstrate the improvements they are making and recognise where further work is required.

“Through our safety investigations it became clear that there is no consistent approach that supports us to objectively articulate the impact an organisation’s safety culture may have had on a patient safety incident occurring and the response. We developed our structured and evidence-based tool COMPASS to feedback on improvements that can be made.

“We believe the tool will help our investigations to reflect on a trusts cultural approach to safety informing improvements in patient safety across maternity and newborn services.”

Notes to editors:

For media enquires please contact Sophie Anderton, Senior Media Advisor: sophie.anderton@cqc.org.uk

For questions about the COMPASS tool, please contact: enquiries@mnsi.org.uk

Related news

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…
Read the full article

World Pre-eclampsia Day 2026

On World Pre-eclampsia Day, MNSI reflects on findings from maternal death investigations between 2020 and 2026, identifying recurring safety issues including delayed diagnosis, inconsistent monitorin…
Read the full article

MNSI responds to the Independent Investigation into Maternity and Neonatal Services in England

Responding to the Independent Investigation into Maternity and Neonatal Services in England
Read the full article

MNSI responds to the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust

Responding to the findings, conclusions and essential actions from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust
Read the full article

MHRA acts on blood transfusion safety following MNSI investigation

The Medicines and Healthcare products Regulatory Agency (MHRA) has published new Device Safety Information on blood transfusion sets, building on an MNSI investigation and Safety Spotlight from last …
Read the full article
© 2026 MNSI. All rights reserved.