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Learning from adverse outcomes in maternity and the role of the Healthcare Safety Investigation Branch

Learning from adverse outcomes in maternity and the role of the Healthcare Safety Investigation Branch (HSIB)

By James Titcombe


This month, a new Bill was presented to the House of Lords to give the Healthcare Safety Investigation Branch (HSIB) new statutory independence from the NHS alongside a range of new powers. The new independent body will be called the Health Service Safety Investigations Body (HSSIB). Whilst the new Bill has been welcomed as an important step towards establishing HSSIB as a truly independent body, its publication has also sparked concerns about the lack of provision for HSSIB to continue HSIB’s current programme of maternity investigations. The government has since confirmed that it only intends for HSIB to continue these investigations until such point as the new Bill becomes enacted, currently anticipated to be 2021.

HSIB’s current maternity work

HSIB was established in 2017 to carry out independent investigations into systemic patient safety incidents using a methodology that focused on system-wide learning, not individual blame.

In 2018, the former Secretary of State for Health, Jeremy Hunt, asked HSIB to start a separate programme of work to investigate certain maternity related incidents. This decision was prompted by strong evidence from multiple investigations and reports that found local investigations into such incidents were sometimes inadequate, failing to provide open and honest answers for families and resulting in opportunities to learn to promote safer care in the future being missed.

In 2015, the Morecambe Bay Investigation report  made a recommendation (23) for clear standards to be introduced for the investigation of ‘…maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths’ and that these standards should…include input from and feedback to families and independent, multidisciplinary peer review.’ The commencement of HSIB’s programme of maternity investigations was an important step in addressing this recommendation.

This work is also seen as an important part of the Government’s National Maternity Safety Strategy, with an ambition to halve the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries that occur during or soon after birth by 2025.

Progress so far

From the 1st of April 2018, HSIB became responsible for the investigations of maternity incidents that met the programme criteria, approximately 1,000 cases per year.  HSIB has now trained over 140 maternity investigators and team leaders. A new, innovative family engagement model has been introduced and HSIB reports that 97% of families have agreed to be involved in the investigations. In due course, HSIB will publish thematic reports from analysis of the themes of these investigations with system-wide recommendations for improvement.

However, last year, the Joint Committee’s report on the Draft Health Service Safety Investigations Bill raised a number of concerns about HSIB’s maternity investigations, stating that the work risked  ‘confusion about HSSIB’s intended purpose’ and recommended that the scope of work was transferred to NHS Improvement. However, the government’s response to the Joint Committee’s report stated that there should be provision in the revised Bill to allow the new body to undertake the maternity investigations, with ‘…flexibility in how long the maternity investigations should continue under the new body’s remit.’

What next…?

The HSSIB Bill as published currently provides no statutory basis for the new body to continue the existing programme of maternity investigations. Therefore, unless the Bill is amended, such investigations could no longer be carried out once the Bill is enacted, which is likely to be sometime in 2021.

This feels like a very short time period, given that the programme was only fully rolled out last year and that HSIB has had to go through a significant learning curve to develop and refine an investigative methodology and build up a team of trained investigators with the expertise  to  complete maternity investigations. It is also crucial that enough time is given to ensure that highquality thematic analysis of the investigations can be carried out, so that the national learning from the work is not lost.

Crucially, we must remember the reasons why this work was initiated in the first place. There remains strong evidence that local organisations often lack the expertise and capacity to carry out these important investigations to consistent standards. Only last week, the first annual report looking at the learning from the roll-out of the National Perinatal Mortality Review Tool, highlighted that only 9% of reviews involved an external panel member, only 16% met the minimum recommended review panel composition, and half of the resulting action plans were graded as ‘weak’.


Baby Lifeline believes that ensuring high quality investigations/reviews of all adverse events in maternity services is essential to maintaining and improving maternity safety. Furthermore, high quality learning processes are a crucial component of providing proper support for families and ensuring staff are treated consistently and fairly, promoting a culture that supports system learning and openness and honesty when things go wrong.

The reality is that in the past, the quality of local investigations has been inconsistent and often poor, contributing to additional distress for families and sometimes a tragic failure to learn, meaning the factors that contribute to poor outcomes are not always identified or addressed.

The programme of work currently being undertaken by HSIB provides a unique opportunity to change this and we must not throw this away by ending the programme prematurely.

Whilst it seems inevitable that HSIB’s remit will at some point be phased out, it is crucial that this only happens once alternative capability and capacity to carry out equally high-quality investigations/reviews is put in place and can be demonstrated.


From February 2020, Baby Lifeline is  commencing a new 2day training programme: Learning from Adverse Events in Maternity Services. This programme has been developed in collaboration  with experts from Cranfield University, NHS Resolution, HSIB and NHS Improvement. This training course is designed to provide local organisations and staff with practical training and knowledge to improve the quality of investigations and learning following adverse events. Further information about this course in available here.


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