A radiographer's hand operates an ultrasound scanner.

Summary of themes arising from the HSIB maternity programme

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

This national learning report highlights the themes emerging from the initial investigations carried out as part of our maternity investigation programme. It looks at maternity investigations carried out by HSIB between April 2018 and December 2019.

Our national learning reports offer insight and learning about recurrent patient safety risks in NHS healthcare that have been identified through HSIB investigations. The reports present a digest of relevant, previously investigated events, highlight recurring themes and, where appropriate, make safety recommendations.

National learning reports can be used by healthcare leaders, policymakers and the public to aid their knowledge of systemic patient safety risks and the underlying contributory factors, and to inform decision making to improve patient safety.

Since April 2018 our maternity investigation programme has started over 1,000 independent safety investigations in NHS maternity services in England. By December 2019, the programme had completed 280 investigations. A further 145 investigations were finalised and undergoing factual accuracy review by families and NHS trusts.

Once completed, all maternity safety investigation reports are provided to the family and the NHS trust involved to ensure appropriate actions are taken.

This report summarises eight prominent themes that have emerged through analysis of completed maternity investigations. It sets out how HSIB will explore these themes in more detail during the coming year.

The themes are:

  • Early recognition of risk
  • Safety of intrapartum care
  • Escalation
  • Handovers
  • Larger babies
  • Neonatal collapse alongside skin-to-skin care
  • Group B Streptococcus
  • Cultural considerations

We plan to publish a series of reports on the above eight themes in 2020/21.

These themes are not exclusive of each other. As the HSIB maternity programme progresses and more information becomes available, we will use this data to inform future investigations and reports.