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Briefing paper: Newborn cooling practices

Briefing paper

MNSI has reviewed 20 investigations into the cooling of term babies across England. The findings show that national guidance on continuous temperature monitoring during cooling was not followed in half of cases.
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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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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 Stakeholder Bulletin

Stakeholder bulletin

On this page you'll find our bi-monthly Stakeholder. Sign up here to be the first to hear the latest news, safety prompts and recommendations and catch up on previous issues through the links on this page.
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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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