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. 
Read Publication

Neonatal collapse alongside skin-to-skin contact

National learning report

HSIB legacy publication

National learning report
Read Publication

Maternity investigation programme year in review 2022/23

HSIB legacy publication

Summary of highlights, themes and future work.
Read Publication

Maternity investigation programme year in review 2021/22

HSIB legacy publication

Summary of highlights, themes and future work.
Read Publication

Maternity investigation programme year in review 2020/21

HSIB legacy publication

Summary of highlights, themes and future work.
Read Publication

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, …
Read Publication

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.
Read Publication

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.
Read Publication

MNSI Annual Report 2023-24 Published

Annual report

MNSI launches it's annual report
Read Publication

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

National learning report

HSIB legacy publication

National learning report.
Read Publication
© 2026 MNSI. All rights reserved.