Our maternity investigations follow a thorough, independent and impartial process. They focus on learning and do not seek to find blame or fault. The involvement of the family is very important to us to understand their experience of what happened.
Our maternity investigations:
- Identify the factors that may have contributed towards death or harm.
- Use evidence-based accounts to establish what happened and why.
- Make safety recommendations and findings where relevant to improve maternity care both locally and nationally.
What the NHS trust does
Make the referral and upload the case notes to the secure investigation management system (known as HIMS). The NHS trust remains responsible for reporting the incident. Incidents involving babies with a potential severe brain injury, where there is clinical or MRI evidence of neurological injury, should also be reported to the NHS Resolution (NHSR) Early Notification (EN) Scheme, quoting the MNSI reference. The incident should be reported to MBRRACE-UK where required. Where cases meet the criteria for reporting to the Perinatal Mortality Review Tool, the NHS trust completes this in collaboration with MNSI.
When a case meets criteria for referral, inform the family, ask for the family’s agreement for MNSI to contact them and provide further information about us, including the MNSI family card. Complete initial duty of candour.
Scan all relevant notes relating to the case and upload to HIMS. Identify and inform us of NHS trust staff involved in the case. Support staff to engage in the investigation by providing information about us, including the staff information leaflet.
What the Maternity and Newborn Safety Investigations programme does
Phone the NHS trust within one working day.
Contact the family within five working days. This happens after the trust has completed the initial Duty of Candour, informed the family about the referral and the family has agreed to contact from MNSI. Get consent for access to their medical notes Discuss the best way for ongoing communication. Arrange an initial video call or in person meeting at an agreed location. Keep the family informed of the investigation's progress.
Review notes and evidence. Arrange an interview with staff involved by video call or in person. Subject matter advisor review team (SMART) review. Subject matter advisors are experienced clinicians and medical consultants in the relevant medical speciality under review. Discuss and agree terms of reference for the investigation and identify key lines of enquiry send to the family and the NHS trust.
Identify any gaps in the evidence and consider how relevant information may be obtained. Where this is not possible this is reflected in the report. Consider findings and potential safety recommendations. Organise second SMART review. Keep the family and NHS trust informed of the investigation's progress.
Draft report is reviewed at report panel. Report panels may be attended by relevant clinical subject matter advisors who provide advice and guidance to the investigation team. Draft report is shared with the NHS trust who are asked to share with any staff involved to check for factual accuracy. Draft report is shared with the family to check for factual accuracy.
Final report shared with the family. Final report shared with the NHS trust and other appropriate organisations. It is the NHS trust's responsibility to share the report with the local integrated care board (ICB).