The Maternity and Newborn Safety Investigations (MNSI) programme published its 2023/24 annual report in November 2024. The MNSI programme carries out independent investigations of patient safety incidents in maternity care, making safety recommendations to improve services both at a local level and across the whole maternity healthcare system in England. Paralegal Iman Samad examines the report and its key findings.
The MNSI programme works with all 121 trusts providing maternity care in England. By the end of March 2024, it had completed 3,505 maternity investigations since being launched in April 2018.
The annual report aims to provide healthcare organisations, policymakers and the public with an insight into the MNSI’s work. It highlights the work done in 2023/24 and its plans for the upcoming year.
Maternity and Newborn Safety Investigations Programme Highlights from 2023/24
Highlights of the work done in the past year include:
- The development of a tool by MNSI investigator Louise Roe used to support the way staff are approached following a patient safety event.
- Publishing a bimonthly bulletin for stakeholders and both clinical and non-clinical staff working in maternity care and patient safety.
- Collaborating with MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) and contributing to chapters in its annual report focusing on maternal deaths and deaths from venous thromboembolism.
- Delivery of a tailored training programme by the charity Birthrights designed to empower the MNSI team to understand human rights and systemic racism in maternity care.
Areas of focus for 2024/25
The annual report highlights how equality, diversity and inclusion (EDI) data has consistently demonstrated that women and birthing people from a non-white background have poorer outcomes than those from white backgrounds.
In response to this data, MSNI has developed a Health Equity Assessment and Resource Toolkit (HEART) aimed at improving the recognition and analysis of health inequalities within their maternity investigations. This includes a calculation of a Health Equity Warning Score (HEWS), designed to stratify a woman or birthing person’s risk of experiencing barriers to health equity. The data from HEART and HEWS will be used to analyse trends in common health equity challenges and develop targeted interventions.
Report’s conclusion
The conclusion of the annual report comes with a reaffirmation that the mission of MNSI continues to improve the safety of maternity care for all women and birthing people, their babies and their families.
Anita Jewitt, Head of the Clinical Negligence department at Stewarts, is recognised as a leading individual representing children who have sustained a brain injury following failures at or around the time of their birth. In response to the publishment of the annual report, she said below.
"It is positive that equality, diversity and inclusion data is a core focus of the work of MNSI in maternity investigations, and I hope this focus extends to the point of delivery of care to address health inequalities. The report states that the MNSI team repeatedly hears families say they do not want others to go through the same experience. This, too, is a theme we hear from the families we represent at Stewarts. MNSI acknowledges in its report that this remains an ambition within maternity care in England that has yet to be achieved."
“In total, during 2023/2024, the MNSI made 1,012 recommendations, and these followed these five themes:
- Clinical assessment
- Fetal monitoring
- Escalation
- Clinical oversight
- Risk assessment
We welcome the MSNI stating that over the coming 12 months, it wants to explore opportunities to expand its work further to keep this area a priority within the overall healthcare agenda.”
The annual report can be accessed here.
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