A step-by-step guide to our maternity investigation process, for families involved in our investigations.

Referral by NHS trust

  • The NHS trust refers your case to the Maternity and Newborn Safety Investigations (MNSI) programme.
  • The NHS trust informs you about MNSI and asks for your agreement to pass your contact details to us.
  • The NHS trust gives you our introduction card, with details of this website.

Initial contact by MNSI

  • One of our investigators contacts you and gives an overview of our maternity investigation process.
  • We ask for your permission to access the relevant medical notes and to process this personal data as part of the investigation (medical notes and interviews).
  • You and your investigator discuss how and to what extent you would like to be involved in the investigation.
  • The investigator will ask you some questions about your individual needs and how we may best meet these.

Initial meeting with MNSI

  • With your agreement we arrange an initial meeting between you and our investigators.
  • We explain the maternity investigation process in more detail, and you can ask any questions you may have.
  • We can talk about other services that are available to offer you help and support.
  • You can change your mind about participating in the investigation at any point, but this does not mean our investigation will stop.


  • We arrange to interview you and other key family members about your experience. This can be done by video call or in person interviews. If you would find it easier to be involved in a different way, for example in writing or over the phone, we can discuss different options. Investigators will not engage in this process if a legal representative is present.
  • We discuss the terms of reference of the investigation.
  • We revisit any support you may require.
  • We want our investigation to be as thorough as possible. This means we might need to speak to you (or a nominated person) more than once. If your contact details or needs change it’s important to tell your investigator.

NHS staff interviews

  • Your investigators interview key members of NHS staff.
  • Investigators seek expert advice about your experience from a panel of experienced clinicians.
  • Investigators keep you updated on the progress of the investigation.


  • Investigators analyse findings.
  • Further clinical advice is sought to review the progress of the investigation.
  • Investigators keep you updated on the progress of the investigation.

Draft report

  • A draft report is prepared detailing what happened, any findings and safety recommendations.
  • The draft report goes through a comprehensive quality assurance process.
  • The draft report is shared with you and the NHS trust. We explain the details to you. We can discuss any details that you have told us about that you believe has been written inaccurately.

Final report

  • We give the final report to you and the NHS trust.
  • We talk to you about the opportunity to hold a three-way meeting between you, us and the NHS trust to discuss any next steps. This is led by the NHS trust.
  • The report may also be shared with the coroner if requested.
  • The investigation concludes.


  • We ask you and your family to feedback and tell us about your experience of our maternity investigation process, so that we can continuously improve it.
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