Annual publication of maternity safety investigation recommendations

As a patient safety programme we are committed to ensuring that our work is carried out transparently, in a way that supports and improves the safety of maternity services in England.

The safety reports developed as part of our maternity safety investigations are shared with the families and NHS trusts involved. To ensure the confidentiality of the mothers/birthing people, their babies and families our reports are not publicly published. However, we share information gathered as part of our investigations as thematic publications and these may include safety prompts or recommendations for all NHS trusts to consider and implement.

In response to a recent freedom of information request and a review of our approach to sharing information gathered as part of our maternity safety investigations, we have accelerated our intention to publicly publish all safety recommendations made in our investigation reports on an annual basis. Safety recommendations were made to organisations when the findings identified during an investigation are considered to be contributory to the outcome.

The safety recommendations shared will align to the investigations completed within the time frame associated to the annual report. 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 would also be keen to hear any feedback you have on the new process to share maternity safety recommendations so we can improve – this can be shared using the above email address.

We will publish all recommendations that do not inadvertently identify a mother/birthing person, baby, family or NHS trust. The safety recommendations will be published alongside our Annual Report which outlines our annual activity.

The safety recommendations from MNSI investigations completed from 1 April 2023 to 31 March 24 can be found in the link above.

The MNSI programme is currently reviewing our information requests to explore how these can be shared on our website.