Learning from investigations where intrapartum care has been given at home
National learning report
National learning report
Read Publication
Letters sent to trusts
Letters
Read the letters previously sent to trusts
Read Publication
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.
Read Publication
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.
Read Publication
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.
Read Publication
Safety Spotlight: Therapeutic cooling practices
Safety spotlight
Our investigations into therapeutic cooling practices have identified areas of learning in relation to passive cooling.
Read Publication
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).
Read Publication
Safety Spotlight: Delayed escalation in abnormal CTGs
Safety spotlight
MNSI has completed a number of investigations in which time limits, as described in national guidance, have delayed categorisation of CTG recordings, resulting in delays in escalation.
Read Publication
Safety Spotlight: Deaths from Anaphylaxis
Safety spotlight
MNSI is aware of maternal deaths from anaphylaxis.
Read Publication
Safety spotlight: Reviewing and actioning laboratory test results
Safety spotlight
MNSI has undertaken investigations where laboratory test results have not been reviewed and actioned.
Read Publication