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Safety spotlight HSIB legacy publication National learning report Poster gallery Safety improvement example Briefing paper Safety recommendations Annual report Stakeholder bulletin Strategy Thematic review Programme Letters Conferences

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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Neonatal collapse alongside skin-to-skin contact

National learning report

HSIB legacy publication

National learning report
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Maternity investigation programme year in review 2022/23

HSIB legacy publication

Summary of highlights, themes and future work.
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Maternity investigation programme year in review 2021/22

HSIB legacy publication

Summary of highlights, themes and future work.
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Maternity investigation programme year in review 2020/21

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

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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Second COMPASS programme launched

Programme

We are announcing today a second pilot programme of our innovative assessment tool designed to examine the impact of organisational culture on safe care. The initial pilot of the MNSI tool, called COMPASS – Culture of Organisations and its iMpact on PAtientS’ Safety ­­– ran in spring 2025.
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MNSI Annual Report 2024/25 published

Annual report

MNSI’s Annual Report 2024/25, highlights work carried out between April 2024 and March 2025 to improve maternity and newborn safety in England.
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MNSI Annual Report 2023-24 Published

Annual report

MNSI launches it's annual report
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Learning from maternal death investigations during the first wave of the COVID-19 pandemic

National learning report

HSIB legacy publication

National learning report.
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