Annual publication of MNSI safety recommendations 2024-25

Our approach to sharing safety learning

As a patient safety programme, we are committed to sharing learning in a way that supports improvements in maternity and newborn services while protecting the confidentiality of women, babies and their families.

Investigation reports are shared with families and the NHS trusts involved but are not published publicly. Instead, learning is shared through thematic publications, safety spotlights, webinars and briefing papers.

Annual publication of recommendations

From 2023/24, MNSI committed to publishing all safety recommendations made in its investigation reports on an annual basis. This enables NHS organisations to review the recommendations and consider whether they apply to their services and where improvements could be made.

Safety recommendations 2024/25

Between 1 April 2024 and 31 March 2025, MNSI completed 613 investigations and made 1,122 safety recommendations to 126 healthcare organisations, including acute and ambulance trusts, GP practices, LMNS, ICBs and regional maternal medicine networks.

MNSI safety recommendations overview 2024/25

• The most frequent themes to generate recommendations included clinical assessment, escalation, guidance, clinical oversight, communication
• 107 of the 126 organisations were acute trusts
• Median number of recommendations per organisation: eight
• Median number per investigation report: two
• Recommendations may be repeated or directed to multiple organisations where the same issues were identified
• Recommendations are directed to organisations, not at national level, but may draw on existing national guidance

We hope that this annual publication will allow all NHS organisations to review and consider whether any of the recommendations apply to their service and if patient safety improvements could be made.

As outlined above, to protect the confidentiality of mothers/birthing people, babies and their families we do not publicly publish our investigation reports. This means that some recommendations published as part of this information sharing process will lack the context within which they were made. We would encourage any trust wishing to learn more about a safety recommendation to contact us by emailing enquiries@mnsi.org.uk and we will support them to do so.

We publish all safety recommendations that do not inadvertently identify a mother/birthing person, baby, family or NHS trust.