The report provides an overview of the work of the MNSI programme
during 2023/24. It sets out the activities carried out by the
investigation team since October 2023 when it transitioned to be
hosted by the Care Quality Commission (CQC). It also details
their plans and priorities for the year ahead.
Sandy Lewis, Programme Director of the Maternity and
Newborn Safety Investigation Programme,
said:
“Our annual report shines a light on the work we have done in
2023/24 and highlights our plans for the future as we move into
2025.
“The personalisation of maternity care to tackle health
inequalities needs to be at the forefront of maternity practice
to ensure safe outcomes for all mothers and birthing people. Over
the past year, we have worked to improve communication between
maternity teams, women/birthing people and families detailed in
our blogand through our
family and staff information videos. Using our Family Inclusivity
Toolkit we have now gathered two years of data which helps ensure
we are inclusive in how we work with families during our
investigations.
“There are significant differences in outcomes for black/ethnic
minority women/birthing people and their babies. Going forward,
we will continue to push for the prioritisation of personalised
care, including continuing to highlight the importance of
equitable outcomes. MNSI is developing a detailed understanding
of the factors that support and promote health equity. Staff
training sessions have helped us to further explore inclusivity
in our work and with the development of our new Health Equity
Assessment and Resource Toolkit (HEART) we will ensure health
equity factors are systematically considered in every
investigation.
“MNSI's thematic learning provides a unique and holistic view of
maternity care in England. We have used these to strengthen our
investigation processes, and reports, and have collaborated with
other organisations to share our learning and influence the
system wide changes which are needed.
“Each family we speak to shares their experience with our team
and we aim to provide them with answers to their questions though
our investigation process. We repeatedly hear their hope that no
other family goes through what they have experienced, but
acknowledge this remains an ambition within maternity care in
England which is yet to be achieved. Taking the action required
to ensure that everyone receives safe, personalised maternity
care must therefore be prioritised and sustained. We are
committed to playing our part in the system-wide change which is
needed to turn this ambition into reality
“Ensuring safe care across maternity services for women/birthing
people and their babies remains a system-wide priority. We will
continue to build on our priorities and work with families, our
staff, and the wider maternity system to strive for safe and
equitable care.”
Minister for Women's Health Baroness said:
"There are unacceptable inequalities in
maternity care across the country.
“This government is working to make sure all women and their
babies receive safe, personalised and compassionate care,
regardless of their background or ethnicity.
“We will learn lessons from recent investigations, and the work
undertaken by the MNSI is an important part of improving
services.”
Ends
Notes to editors
An embargoed copy of MNSI's Annual Report October 2023/March 2024
is attached. The report will be available on the MNSI website
(https://www.mnsi.org.uk)
from Thursday 7 November 2024.
Maternity and Newborn Safety Investigations programme
(MNSI)
MNSI is the leading body for maternity and newborn safety
investigations in England. The Maternity and Newborn Safety
Investigations (MNSI) programme investigates certain cases of:
- Early neonatal deaths, intrapartum stillbirths and severe
brain injury in babies born at term following labour in
England.
- Maternal deaths in England.
The programme of investigations into maternity and newborn safety
incidents was previously overseen by the Healthcare Safety
Investigation Branch (HSIB). It began in 2018 as part of the
national initiative to improve safety in maternity care. From 1st
October 2023, MNSI has been hosted by the Care Quality
Commission. There has been no change to how hospital trust
maternity services in England refer incidents or concerns to the
MNSI team. The MNSI team continues to investigate and report
their findings in the same way.
