1,700+ safety recommendations in latest HSIB maternity report | Fieldfisher
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1,700+ safety recommendations in latest HSIB maternity report

Arti Shah
HSIB, the independent Health Safety Investigation Branch of the NHS, has published its maternity 'year in review' report, highlighting the findings of its maternity investigation programme 2021-22.

HSIB, funded by the Department of Health and Social Care, was set up four years ago to investigate and improve patient safety through independent investigations into NHS-funded care across England. The maternity unit works with patients and their families affected by maternity failings and negligence, 125 NHS trusts and medical staff to investigate when something goes wrong.

It investigates incidents that meet the criteria defined within the Each Baby Counts programme (the Royal College of Obstetricians and Gynaecologists’ national quality improvement programme, now closed) or its own defined criteria for maternal deaths.

Criteria for investigation

Incidents eligible for investigation include those that involve term babies (at least 37 completed weeks of gestation) who experience one of these outcomes:

  • Intrapartum stillbirth: Where the baby was thought to be alive at the start of labour and was born with no signs of life.
  • Early neonatal death: Where the baby died within the first week of life (0 to 6 days) of any cause.
  • Severe brain injury: Where the baby was diagnosed with severe brain injury in the first 7 days of life. This includes babies: diagnosed with grade III hypoxic ischaemic encephalopathy (HIE), or who were therapeutically cooled (active cooling only), or were born ‘floppy’, were comatose (loss of consciousness) and had seizures of any kind.
  • Maternal deaths: The death of a woman while pregnant or within 42 days of the end of the pregnancy from any cause related to or aggravated by the pregnancy or its management.

Incidents are referred by the NHS trust where the incident took place, and HSIB's investigations generally replace the trust’s own internal investigation. The report is then shared with the family and the trust, which in turn is responsible for carrying out any safety recommendations.

Headline points

The majority of cases investigated concern cooled babies or those diagnosed with brain injuries. Headlines from the most recent report last year include:

  • 706 reports completed
  • more than 1,740 safety recommendations to NHS trusts addressing a range of issues
  • 22 national investigation reports, including thematic reviews
  • 73 national safety recommendations
  • newsletter to support NHS trusts to share improvements in response to safety recommendations, providing learning opportunities across England and beyond.

The report states that investigations often identify multiple opportunities when a different course of action or pathway of care could have been followed and specifically highlights the importance of communication and response where decisions require an emergency response. A race equality group has been implemented to consider the impact of race on experiences and outcomes.

Areas of concern

Several areas of concern relating to different trusts were identified, such as:

  • categorisation of Caesarean sections
  • situational awareness of deteriorating CTG traces
  • fetal monitoring and appropriate escalation
  • not recognising chronic hypoxia on CTGs
  • misclassifying CTGs
  • appropriate categorisation of liquor
We see many of these in the cases we run. For example:

The future

In April 2023, HSIB will reform into two separate bodies – the Maternity and Newborn Safety Investigations Special Health Authority (MNSI) and the Health Services Safety Investigations Body (HSSIB).

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