The Maternity and Newborn Safety Investigations (MNSI) programme investigates certain cases of:

  • early neonatal deaths, intrapartum stillbirths and severe brain injury in babies born at term following labour in England
  • maternal deaths in England.

Full details of what we investigate can be found below.


Babies who meet our criteria include all term babies born following labour (at least 37 completed weeks of gestation), who have one of the following outcomes:

  • intrapartum stillbirth
  • early neonatal death
  • potential severe brain injury.

We do not investigate cases where health issues or congenital conditions (something that is present before or at birth) have led to the outcome for the baby.

The definition of labour that we use includes:

  • Any labour diagnosed by a health professional, including the latent phase (start) of labour at less than 4cm cervical dilatation.
  • When the mother called the maternity unit to report any concerns of being in labour, for example (but not limited to) abdominal pains, contractions, or suspected ruptured membranes (waters breaking).
  • Induction of labour (when labour is started artificially).
  • When the baby was thought to be alive following suspected or confirmed pre-labour rupture of membranes.

This means that for us to investigate a maternity incident under the MNSI criteria, the mother must have been in term labour as defined by these conditions.

We do not investigate neonatal cases where the mother has not gone into labour. For example, when a caesarean section was performed before the mother had started having contractions or ruptured her membranes.

Intrapartum stillbirth

Where the baby was thought to be alive at the start of labour and was born with no signs of life.

Early neonatal death

When the baby died within the first week of life (0-6 days) of any cause.

Potential severe brain injury

Potential severe brain injury diagnosed as occurring in the first seven days of life, when the baby:

  • Was therapeutically cooled (active cooling only), or
  • Has been diagnosed with moderate to severe encephalopathy, consisting of altered state of consciousness (lethargy, stupor or coma) and at least one of the following:
  1. hypotonia;
  2. abnormal reflexes including oculomotor or pupillary abnormalities;
  3. absent or weak suck;
  4. clinical seizures.

We no longer routinely investigate cases involving therapeutically cooled babies where there is no apparent ongoing neurological injury following cooling therapy. This would usually mean a brain MRI showing no hypoxic damage (a type of brain injury that occurs when there is a disruption in supply of oxygen to the brain) and the baby demonstrating no ongoing neurological signs or symptoms. However, this remains as one of our criteria. NHS trusts should continue to refer cases to us. We’ll decide which investigations proceed based on an individual baby’s clinical outcome, after discussion with the family and the NHS trust.

Maternal deaths

We investigate direct or indirect maternal deaths of women while pregnant or within 42 days of the end of pregnancy.

We may investigate some maternal deaths which do not entirely fit within these two categories.

We do not investigate cases where suicide is the cause of death.

Direct deaths

Direct deaths include those resulting from obstetric complications of the pregnant state (pregnancy, labour and after the birth), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above.

Indirect deaths

Indirect deaths include those from previous existing disease or disease that developed during pregnancy, and which was not the result of direct obstetric causes but was aggravated by the physiological effects of pregnancy in the perinatal period (during or within 42 days of the end of pregnancy).

When we cannot investigate

Some maternity incidents that meet our criteria will have occurred before our programme began nationally in 2018, or within a period where the programme had not yet been implemented in the NHS trust where the incident took place.

There will also be some incidents with characteristics which fall close to, but not completely within, the scope of the MNSI criteria.

Due to specific conditions set out in the Directions that govern our maternity programme, we have no remit to investigate these incidents and the responsibility to complete the investigation remains with the local NHS trust.

We recognise that this may be disappointing for families who hope to see learning from their personal experience contribute to changes at a national level to improve maternity safety. Please have a look at our list of some of the other organisations who may be able to offer you help and support.

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