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Briefing paper: Birthing outside of guidance

15 January 2025

Briefing paper

We have identified ‘birthing outside of guidance’ as a national learning theme through our maternity investigations. Between September 2018 and December 2023 we have made recommendations relating to birthing outside of guidance 33 times.

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Neonatal collapse alongside skin-to-skin contact

13 August 2020

National learning report

HSIB legacy publication

National learning report

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Maternity investigation programme year in review 2022/23

2 May 2023

HSIB legacy publication

Summary of highlights, themes and future work.

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Maternity investigation programme year in review 2021/22

3 May 2022

HSIB legacy publication

Summary of highlights, themes and future work.

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Maternity investigation programme year in review 2020/21

4 May 2021

HSIB legacy publication

Summary of highlights, themes and future work.

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Briefing paper: Learning from resuscitative hysterotomy after out-of-hospital cardiac arrest

9 September 2025

Briefing paper

The Maternity and Newborn Safety Investigations (MNSI) programme has published a new briefing paper sharing learning from investigations of resuscitative hysterotomy (RH) following out-of-hospital cardiac arrest in pregnancy. The paper is intended to support midwives, obstetricians, anaesthetists, …

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Learning from maternal death investigations during the first wave of the COVID-19 pandemic

25 February 2021

National learning report

HSIB legacy publication

National learning report.

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East Kent Hospitals University NHS Foundation Trust: HSIB summary report

6 April 2020

HSIB legacy publication

A summary of the investigations undertaken with East Kent Hospitals University NHS Foundation Trust.

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Assessment of risk during the maternity pathway

2 March 2023

National learning report

HSIB legacy publication

National learning report.

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Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020

16 September 2021

National learning report

HSIB legacy publication

National learning report.

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