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Foreword from Baroness Merron
The loss of a baby is an unimaginable tragedy. It can leave families with profound grief, unanswered questions, and a longing for understanding. When things go wrong, it is essential that families are supported in understanding the reasons behind their baby's death, are assured that lessons will be learned, and can trust that meaningful improvements will follow.
The Maternity and Newborn Safety Investigations (MNSI) programme plays an important role in this. This strategy sets out a vision for the programme to further embed families' voice into our national priority to improve maternity and neonatal care, reduce unacceptable inequalities in outcomes, and support Trusts to proactively prevent future harm and implement learning through MNSI's intelligence and safety insights.
Independent, family-centred investigations conducted by the MNSI programme uncover the reasons behind such devastating outcomes and support improvements in maternity and newborn care, so that other families may be spared similar pain in the future. Since its inception, the programme has undertaken over 4,300 independent investigations into maternity and newborn care throughout England, uniquely placing it in a position to draw on data and intelligence from previous investigations and identify patterns and emerging risks.
The publication of this strategy takes place against the backdrop of the ongoing independent National Maternity and Neonatal Investigation, led by Baroness Amos. The investigation will help us understand the systemic issues behind why so many women, babies and families experience unacceptable care, and will help us understand how learning and best practice is identified and adopted in institutions and organisations across England. The recommendations made by the national investigation will form the basis of a new national action plan, that will be developed by a National Maternity and Neonatal Taskforce, to be chaired by the Secretary of State for Health and Social Care.
Given this context, it is vital that the MNSI remains adaptive and responsive. I believe that this strategy will allow the programme to adjust to new developments and recommendations as they arise, whilst maintaining its commitment to delivering high-quality, independent maternity and newborn safety investigations.
I would like to express my gratitude to everyone involved in the MNSI programme for their passion, expertise, and dedication. Their ongoing efforts are instrumental in shaping a safer future for mothers and newborns across the country. I look forward to seeing the positive impact of this strategy as we work together to achieve our shared goals.
Welcome from our Programme Director, Sandy Lewis, and Clinical Director, Louise Page.
Welcome to our strategy for 2025-27, Building a safer future through partnership and prevention, where we set out our strategic priorities and ambitions.
Since formation, the Maternity and Newborn Safety Investigations programme (MNSI) has become a recognised voice in safety, conducting more than 4,300 independent investigations into maternity and newborn care across England.
This strategy marks a new chapter: moving from describing what went wrong to working proactively with the system to prevent future harm through partnership, innovation and meaningful engagement with families and professionals.
The policy landscape is evolving. The Dash Review (2025) called for greater coherence across patient safety bodies, while the NHS 10 Year Health Plan highlighted maternity and newborn care as a priority for data, equity and personalised care. In parallel, the National Maternity and Neonatal Investigation is drawing together lessons from multiple inquiries to inform and drive systemic reform.
Despite progress, significant challenges remain. The stillbirth rate in England is 3.9 per 1,000 births and neonatal mortality is 1.4 per 1,000 live births, both above the 2025 ambition to halve 2010 rates (ONS 2023, NHS England 2025). Moreover, the latest MBRRACE-UK data shows that Black women are 2.3 times more likely and Asian women 1.3 times more likely to die in childbirth than White women, underlining persistent racial inequities in maternal health outcomes.
Our engagement with families, NHS trusts, national partners and MNSI colleagues has shaped this strategy and shown the way forward. MNSI must strengthen its leadership role within the new integrated safety system while maintaining investigative excellence. This strategy sets out how we will work towards this by building authentic partnerships, embedding equity, and supporting trusts to translate learning into sustained safety improvements. This will enable NHS trusts and healthcare professionals to prevent harm before it occurs. Real progress will require collective effort and we call on all partners across the NHS, government and communities to join us in this mission.
We extend our sincere thanks to the families, NHS trusts, partners and MNSI colleagues who contributed to shaping this strategy. Their insights and experiences form the foundation of our ambition to make maternity and newborn care safer for everyone, especially those who experience most disadvantage.
Sandy Lewis
Programme Director, MNSI
Louise M Page
Clinical Director, MNSI
Executive summary
The Maternity and Newborn Safety Investigations (MNSI) programme is at a pivotal stage. We have established ourselves as a trusted investigation service, yet the changing safety landscape demands that we build broader capabilities beyond traditional investigation alone.
Against the backdrop of the 10 Year Health Plan's emphasis on prevention and artificial intelligence (AI)-enabled analysis, the Dash Review's call for integrated safety governance and the government's commitment to resetting relationships with the public, we must evolve from reactive investigations to proactive safety leadership.
Over the next two years, we will expand our role beyond investigation alone. By developing AI-enabled predictive intelligence alongside our investigation work, we will support the system to identify and address risks earlier.
This strategy sets out how we will change the way safety improvement happens in England.
We recognise that the future remit and operating model of MNSI beyond 2027 will be shaped by decisions from government and by any recommendations arising from the national investigation. Our strategy is therefore designed to be adaptive, ensuring we can respond appropriately to these developments while continuing to deliver high-quality, independent maternity and newborn safety investigations.
Our key strategic commitments:
- Support NHS trusts to identify emerging risks and take proactive action to prevent harm to women and newborn babies.
- Embed equity and inclusion approaches to systematically address health disparities and reach underserved populations.
- Ensure meaningful engagement with families, formalising their role in governance to inform safety improvements across the system.
- Invest in the people who deliver MNSI’s work, providing training, career progression and wellbeing support to equip staff to support trusts, families and each other effectively.
To achieve this, we will be guided by three interconnected themes:
Excellence in building our internal capacity and governance while sustaining the high investigation quality that defines our credibility.
Impact through harnessing technology and our unique dataset of more than 4,300 completed investigations to move beyond reactive work toward predictive safety intelligence.
Relationships by embedding authentic family voice, strengthening professional partnerships and fostering system collaboration to drive sustained safety improvements.
About us
Our role
We are the Maternity and Newborn Safety Investigations (MNSI) programme. We operate as an independent programme tasked with:
- Conducting thorough, independent investigations into maternity and newborn care across England.
- Working authentically with families and healthcare professionals to understand why safety events occur and to develop safety recommendations and safety prompts for individual trusts and thematic learning for the wider NHS.
- Translating investigation findings into intelligence that supports the system to prevent harm before it occurs, moving beyond reactive response toward proactive prevention.
- Providing unique system intelligence through our substantial dataset of more than 4,300 completed investigations, offering insight into patterns, trends and systemic factors affecting maternity and newborn safety.
MNSI employs approximately 200 staff across four regions, combining clinical expertise with investigation skills to deliver high-quality, family-centred and system focussed investigations. We have been hosted by the Care Quality Commission (CQC) since October 2023, with dedicated MNSI and CQC team members supporting coordination, communication and data functions.
Our mission
“We conduct independent safety investigations into maternity and newborn events. We listen to and learn from families and healthcare professionals, and we work in partnership to prevent future harm and improve care.”
This mission defines how the programme will achieve its vision through independent investigation excellence, authentic partnership and a commitment to prevention that extends beyond individual investigations to system-wide safety improvement.
Our vision
“A safer future for maternity and newborn care built on listening and learning through independent safety investigations.”
This vision captures our commitment to a future where safety is built on the foundation of authentic listening to families and learning from healthcare professionals through rigorous, independent investigation.
MNSI values
Our values - collaboration, integrity, excellence, and learning - guide all aspects of our work and shape our interactions with families, stakeholders, and MNSI staff alike. As part of this strategy, MNSI will refresh its core values to reflect our evolving role in maternity and newborn safety and to align more closely with those of our host organisation, the CQC, while ensuring that our vision and mission continue to safeguard our independence.
Excellence: We are effective in maintaining the highest level of excellence
Collaboration: We are supportive of others and value working together to achieve our goals
Learning: We will grow and learn as individuals and as an organisation
Integrity: We act with sincerity, openness, honesty and respect
Current position
Maternity and newborn care in England continues to face intense national scrutiny.
Despite considerable policy focus and system-level responses, avoidable harm persists, and health inequalities remain deeply entrenched. The quality and consistency of care varies significantly across the country, with the greatest impact felt by women, birthing people, babies and families from marginalised communities.
The following policy developments and initiatives have shaped the context in which maternity and newborn care is delivered, and the landscape in which MNSI operates:
- The NHS 10 Year Health Plan positions maternity and newborn services at the heart of system transformation, emphasising real-time safety intelligence, personalised care and prevention.
- The National Maternity and Neonatal Taskforce and the Maternity Outcomes Signal System (MOSS) create opportunities for MNSI's investigative insights to inform national learning and improve outcomes.
- The Dash Review calls for fundamental reform of the patient safety oversight landscape, recommending consolidation of existing bodies and clearer governance, creating both opportunities and challenges for MNSI's role within an integrated safety system.
- The rapid national investigation of maternity and newborn care (June 2025) signals the government's commitment to unified national oversight, with family voices central to shaping interventions and driving improvement.
These developments present a unique opportunity for MNSI to establish itself as the collaborative safety leader the system requires. MNSI's independence, investigative expertise, family-centred approach and unique dataset position the programme to bridge the gap between national policy ambitions and frontline safety intelligence, driving meaningful improvements across maternity and newborn services.
Strategy: our vision of success by 2027
By 2027, we aim to have made significant progress in our transformation from being a primarily reactive investigation service to one that works collaboratively with the NHS in England to strengthen maternity and newborn safety and help prevent harm before it occurs, while remaining ready to adapt to future system decisions.
When concerning patterns emerge in maternity and newborn services, our AI-enabled safety systems will identify trends quicker than ever before, rather than waiting for serious events to accumulate.
Our investigation teams will concentrate their expertise on the most complex cases requiring deep human factors analysis, while AI systems will manage pattern recognition and early warnings. Each investigation will generate not only recommendations for individual trusts but also insights that support all NHS trusts to manage patient safety risks and prevent harm before it occurs.
Family voices will be embedded throughout our work as partners in governance and design. Our family voices group will shape investigation priorities and methodologies. Community engagement specialists will ensure that safety improvements reach underserved populations who have historically experienced poorer outcomes and limited voice in shaping solutions.
Our staff will find their roles more varied, impactful and professionally fulfilling. Investigators will spend more time on complex analysis than routine case processing. Data scientists will work alongside investigation teams. Career pathways will extend from frontline investigation to international safety leadership.
Most importantly, families across England will experience safer maternity and newborn care because we will be listening more authentically, analysing more intelligently and collaborating more effectively to support the system to prevent harm before it occurs.
Our strategic priorities
Priority 1: Excellence
What success will look like:
We will strengthen MNSI’s foundation by improving governance, developing our analytical capacity and supporting our people, while maintaining the investigation quality that underpins our credibility. This focus ensures we can respond effectively to evolving safety challenges and take on an expanded role.
How we will achieve this:
- Streamline governance: clarify decision-making and programme structures so that teams can work efficiently and strategically across regions.
- Build analytical capability: develop expertise to turn investigation data into insights that directly support maternity and newborn safety.
- Standardise quality: apply consistent investigation standards to ensure families receive high-quality support and NHS trusts can learn from investigations across the country.
- Enhance operations: strengthen administrative and technical systems to allow investigators to focus on the most impactful work.
- Invest in our people: provide clear career paths and wellbeing support to equip staff for an intelligence-led, forward-looking role.
Impact on maternity and newborn safety:
By maintaining investigation excellence and strengthening the programme's analytical capabilities, we deliver insights that help families, NHS trusts and the wider system improve to safety outcomes for mothers and newborns.
Priority 2: Impact
What success will look like:
Building on our investigatory experience, we will support the national system in identifying and reducing maternity and newborn safety events before they occur. By harnessing predictive intelligence and proactive safety insights, we will enable NHS trusts to anticipate and prevent future harm, while continuing to develop robust ways to demonstrate MNSI’s impact across the healthcare system.
How we will achieve this:
- Develop predictive tools: harness technology to identify emerging risks and provide actionable intelligence to NHS trusts.
- Support the development of early warning systems: detect patterns quickly and enable preventative action before safety events occur.
- Integrate with national initiatives: ensure insights contribute to system-wide safety improvements and inform national policy.
Impact on maternity and newborn safety:
This approach enables trusts to act early to protect families. Each investigation generates learning that strengthens safety across maternity and newborn services nationwide, while helping MNSI demonstrate its impact on the broader healthcare system.
Priority 3: Relationships
What success will look like:
We will build meaningful partnerships with families, healthcare professionals and system partners to drive sustained improvements in safety and equity, ensuring that all communities benefit.
How we will achieve this:
- Engage families effectively: ensure family voices shape priorities and methods, including reaching underserved communities.
- Promote equity and inclusion: implement approaches that reduce disparities and make safety improvements accessible to everyone.
- Strengthen collaboration: work closely with healthcare professionals and stakeholders to make partnership a routine part of our work.
- Lead in the system: position MNSI as a trusted voice in shaping national maternity and newborn safety policy.
Impact on maternity and newborn safety:
By engaging families and deepening collaboration with professionals and communities, we drive improvements that make maternity and newborn care safer and more equitable for all.
Development of this strategy
To develop this strategy, we undertook a comprehensive discovery phase to understand both MNSI's current role and its future potential.
We spoke with 19 stakeholders, including policymakers, arm's-length bodies, NHS trusts, families, royal colleges and third sector partners. We engaged directly with our own staff through four regional focus groups and a leadership workshop, hearing from 60 colleagues across all levels and geographies - with contributions from more than one-third of the programme.
To capture the perspective of NHS trusts more broadly, we ran a 15-question survey, receiving 28 responses on collaboration, investigations, recommendations and MNSI's future direction. We supplemented this with a review of 33 key documents, from policy briefings and governance papers to thematic reports and guidance for families and trusts. Finally, we looked at best practice from peers, including the Health Services Safety Investigations Body and NHS Resolution, and international approaches from Colombia, New Zealand and Japan.
Together, these insights have helped us understand how MNSI can evolve to meet the changing safety landscape and drive improvements in maternity and newborn care. We are enormously thankful to all who engaged with us and helped shape this strategy.
Conclusion
This strategy represents MNSI's evolution from investigation excellence to collaborative safety leadership. Once achieved, MNSI will be recognised as the definitive voice in maternity and newborn safety, not only for the quality of its investigations, but for its ability to translate learning into intelligence that supports system-wide improvements.
The transformation outlined is ambitious but achievable, grounded in evidence and designed to build on existing strengths.
Through developing excellence, impact and relationships, MNSI will create a safer future for maternity and newborn care built on listening, learning and authentic partnerships with families and healthcare professionals.
The families who have shared their experiences with MNSI, the healthcare professionals who engage with its work, and the staff who deliver investigations daily all require this transformation. Together, MNSI will ensure that every woman, birthing person and baby in England benefits from the safest possible maternity and newborn care. The journey toward this safer future begins now.