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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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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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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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East Kent Hospitals University NHS Foundation Trust: HSIB summary report

HSIB legacy publication

A summary of the investigations undertaken with East Kent Hospitals University NHS Foundation Trust.
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Assessment of risk during the maternity pathway

National learning report

HSIB legacy publication

National learning report.
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