Maternity ward sign in a hospital.

Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Investigation summary

The number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year.

The data initiated an HSIB national learning report which explored the findings from our maternity investigations during this time.

Our national learning reports can be used by healthcare professionals, policymakers, and the public to:

  • aid their knowledge of systemic patient safety risks
  • understand the underlying contributing factors
  • inform decision-making to improve patient safety
  • explore wider patient safety processes.

The information in national learning reports is also used to inform future HSIB investigations or programmes of work.

We investigate intrapartum (labour) stillbirths after 37 weeks, where a baby was thought to be alive at the start of labour and was born with no signs of life.

Since the coronavirus (COVID-19) pandemic was declared by the World Health Organization, HSIB has seen a large rise in the number of intrapartum stillbirth referrals to our maternity investigation programme in England.

In 2019, 24 stillbirth referrals were made to HSIB that met maternity investigation programme criteria between 1 April and the end of June. During the same period in 2020 there were 46.

Our national learning report:

  • describes the context within which the intrapartum stillbirths took place
  • seeks to understand why we have seen this increase
  • identifies learning to improve patient safety across the healthcare system
  • shares that learning with NHS trusts across the country.

In addition to our report, we have also published supplementary information related to this investigation.

Investigation report