Learning from investigations where intrapartum care has been given at home
National learning report
National learning report
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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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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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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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Factors affecting the delivery of safe care in midwifery units
National learning report
National learning 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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Assessment of risk during the maternity pathway
National learning report
HSIB legacy publication
National learning report.
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