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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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Briefing paper: Remote hospital working

Briefing paper

A thematic review was conducted to explore the impact that remote hospital working can have on the provision of maternity and neonatal services.
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Safety spotlight: Calling for help in obstetric cardiac arrests

Safety spotlight

This safety spotlight focuses on delays in calling the emergency team during obstetric cardiac arrests.
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Safety spotlight: Nitrous oxide

Safety spotlight

This safety spotlight shares what we found regarding nitrous oxide decommissioning and offers prompts to help providers keep staff informed and equipment checks consistent.
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Launch of new MNSI thematic review: Homebirth

Thematic review

In response to learning identified from MNSI (formally Healthcare Safety Investigation Branch (HSIB)) maternity investigations, MNSI wants to further understand how systems and pathways affect the safe delivery of intrapartum care at home. MNSI started a thematic review in 2025 to understand the th…
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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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Safety Spotlight: Changes to the MNSI investigation report template

Safety spotlight

On 1st April 2024, six months after the transition to being hosted by the CQC, MNSI changed their investigation reports and process.
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Safety Spotlight: Maternal Deaths in the first trimester from Venous Thromboembolism (VTE)

Safety spotlight

MNSI has undertaken investigations of maternal deaths in the first trimester from venous thromboembolism (VTE)
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Safety Spotlight: Incomplete observations generating incorrect EWS

Safety spotlight

MNSI has investigated a number of patient safety events where an incomplete set of observations generated an early warning score (EWS) via an electronic patient record (EPR) system.
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Safety Spotlight: Prescribing and dispensing of low molecular weight heparin

Safety spotlight

Things MNSI recommend considering when prescribing low molecular weight heparin to avoid incorrect doses being dispensed.
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