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Safety Spotlight: Investigations into equipment and technology used for continuous fetal heart rate monitoring

Safety spotlight

MNSI has completed Investigations into equipment and technology used for continuous fetal heart rate monitoring.
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Safety Spotlight: Deaths from Anaphylaxis

Safety spotlight

MNSI is aware of maternal deaths from anaphylaxis.
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Safety Spotlight: Therapeutic cooling practices

Safety spotlight

Our investigations into therapeutic cooling practices have identified areas of learning in relation to passive cooling.
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Safety Spotlight: Exchange blood transfusion

Safety spotlight

A baby received an exchange blood transfusion. This is a specialist and complex procedure with associated risks (and is now infrequently performed in most neonatal units).
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Maternal Care Bundle safety spotlights

Safety spotlight

We welcome the publication of the Maternal Care Bundle by NHS England and are delighted to have been a key contributor in its development. A series of safety spotlights follow.
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Safety spotlight: Late diagnosis of breech presentation

Safety spotlight

MNSI has completed a number of investigations where there has been a late diagnosis, in established labour, of a baby being in breech presentation during an induction of labour.
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Safety spotlight: HbA1c testing in women with sickle cell trait

Safety spotlight

Laboratory tests for glycosylated haemoglobin (HbA1c) can underestimate past glycaemia in people with haemoglobin variants, such as those with sickle cell trait. This is because there is an increased red cell turnover in those with haemoglobin variants. This means that HbA1c tests, which estimate t…
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MNSI thematic learning poster gallery

Poster gallery

On this page you'll find a selection of posters MNSI has presented at maternity and newborn safety conferences
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Investigation information and timescales July 2025

Letters

A letter to trusts re investigation information and timescales
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Briefing paper: Birthing outside of guidance

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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