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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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Annual publication of maternity safety investigation recommendations 2023 to 2024

Safety recommendations

MNSI publishes the safety recommendations from MNSI investigations completed in 2023/24.
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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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Annual publication of MNSI safety recommendations 2024-25

Safety recommendations

MNSI publishes the safety recommendations from MNSI investigations completed in 2024/25.
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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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Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020

National learning report

HSIB legacy publication

National learning report.
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