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Safety Spotlight: Exchange blood transfusion

Safety spotlight

A baby received an exchange blood transfusion. This is a specialist and complex procedure with associated risks (and is now infrequently performed in most neonatal units).
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Maternal Care Bundle safety spotlights

Safety spotlight

We welcome the publication of the Maternal Care Bundle by NHS England and are delighted to have been a key contributor in its development. A series of safety spotlights follow.
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Safety spotlight: Late diagnosis of breech presentation

Safety spotlight

MNSI has completed a number of investigations where there has been a late diagnosis, in established labour, of a baby being in breech presentation during an induction of labour.
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Safety spotlight: HbA1c testing in women with sickle cell trait

Safety spotlight

Laboratory tests for glycosylated haemoglobin (HbA1c) can underestimate past glycaemia in people with haemoglobin variants, such as those with sickle cell trait. This is because there is an increased red cell turnover in those with haemoglobin variants. This means that HbA1c tests, which estimate t…
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Neonatal collapse alongside skin-to-skin contact

National learning report

HSIB legacy publication

National learning report
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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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