Background
The independent National Maternity and Neonatal Investigation, chaired by Baroness Amos, identified that investigation responses to perinatal harm are not coordinated and may be confusing.
This leads to concerns that investigations may be distressing for families and staff, some patient harm may not be subject to investigation, and learning from investigations may not be effectively shared to drive improvements in patient safety.
To support the work of the Maternity and Neonatal Taskforce in responding to Baroness Amos’ recommendations, HSSIB has committed to completing a mapping exercise of publicly available resources with the aim of identifying the different types of investigations that may be undertaken following reports of perinatal harm.
Summary of approach
We will will seek to identify the different types of investigations that occur across the maternity landscape and against each of these investigations will aim to report on.
- The organisation that leads the investigation.
- The type of investigation required and how this is triggered.
- Where the requirement for this investigation comes from and its intended purpose.
- How long an investigation takes and what it produces when it is completed.
- The prescribed or expected role for patients and/or families within these investigations.
This will support ongoing work in response to Baroness Amos’ recommendations to identify the potential gaps and overlaps in the maternity investigation landscape and provide opportunities to reduce duplication and confusion, that can compound harm for people involved in incidents of perinatal harm.