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The leading body for maternity and newborn safety investigations in England |
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A monthly bulletin for stakeholders, clinical and non-clinical staff working in maternity, neonatal care and patient safety.
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Briefing: Birthing outside of guidance
We have identified ‘birthing outside of guidance’ as a national learning theme through our maternity investigations. Between September 2018 and December 2023 we have made recommendations relating to birthing outside of guidance 33 times.
We found there is limited national guidance to help clinical teams supporting women / birthing people who give birth outside of guidance. Our new safety briefing shares information we have gathered through our maternity safety investigations and aims to improve the safety of women / birthing people and their babies, should they birth outside of guidance.
The briefing shares our evidence and insight on this topic and provides prompts for maternity care providers to consider:
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If they have appropriate guidance in place to support maternity staff working with mothers / birthing people birthing outside of guidance
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If they have ensured mothers / birthing people have the information they need to make informed decisions about their care
We welcome any comments or feedback on this new approach to sharing insight and learning from our investigations. You can share your thoughts with us by emailing: enquiries@mnsi.org.uk.
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Following the thematic learnings presented at various conferences in Autumn 2024 we are pleased to announce a series of webinars exploring learnings from our safety investigations. Click on the image below to find out more and register.
In September we welcomed two clinical fellows to support our work to improve maternity safety in England. Our clinical fellows have been supporting a number of projects designed to analyse thematic findings from our investigations as well as supporting us to develop new approaches to our work.
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Meet Dr Chris McQuitty - I’m Chris, I am a GP trainee in my final year of training, and I’ve been working as a doctor for about 10 years in a variety of specialties including emergency medicine, intensive care, anesthetics and medicine.
Click the image to read more about Chris
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Meet Dr Ricia Gwenter - I am a gastroenterology and general internal medicine speciality registrar based in Wessex. Like Chris, I am working with MNSI as part of the National Medical Director’s Clinical Fellow Scheme, which offers resident doctors the unique opportunity to spend a year within a national healthcare organisation.
Click the image to read more about Ricia
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British Intrapartum Care Society (BICS) annual conference
In November we presented at and attended the annual British Intrapartum Care Society (BICS) conference.
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Factors affecting the delivery of safe care in midwifery units: a national learning report from MNSI.
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Umbilical Cord Management During Neonatal Resuscitation Within NHS Policy and Practice: A Systematic Literature Review and Prospective Analysis by MNSI.
Louise Page, MNSI Clinical Director who attended the conference said: “The BICS conference was a great opportunity to share our findings from our national learning report into factors affecting the delivery of safe care in maternity units and our systematic literature review into umbilical cord management during neonatal resuscitation.
“Presenting this work to clinicians supports the broader sharing of our insights and research, enabling maternity teams to implement recommendations and improve maternity safety.
“We really valued the conversations both our presentations generated and interactions with maternity colleagues who visited our stand. These conversations support us to develop our approach and areas of focus.”
 L-R: Lizzy Salway, Angela Foster, Kerry Cunniffe, Louise Page, Louise Wake, Joanna Francis, Helen Smith
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The National Institute for Health and Care Research (NIHR) has funded the COMET trial, which is designed to evaluate the safety and efficacy of induced cooling in babies with mild encephalopathy. The trial is open to babies born at or after 36 weeks of gestation and is being conducted across over 40 National Health Service (NHS) hospitals.
As a result of the trial there may be an increase in MNSI referrals from hospitals participating.
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Delayed escalation in abnormal CTGs
For example: A CTG is started, decelerations are present from the beginning. It is not possible for clinicians to know when the decelerations started.
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In what time frame would this be escalated in your unit?
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Would the expectation be to escalate before 30 minutes have passed?
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Do you include this type of scenario in your CTG training?
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Is your team empowered to escalate prior to confirmation of a pathological CTG or prior to awaiting results of a computerised antenatal CTG?
- Is your team empowered to recognise the potential impact of CTG abnormalities which are present at the beginning of a CTG recording?
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Annual publication of MNSI safety recommendations
In November we announced the annual publication of our safety recommendations following a Freedom of Information (FOI) request.
This means we will now, as a minimum, share the safety recommendations made during our investigations on our website annually. The safety recommendations shared will align to the investigations completed within the time frame associated to our annual report.
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MNSI response to National Maternity Survey results
The CQC published the National Maternity Survey results for 2024 in November.
The survey showed some areas of improvement over the past year, particularly regarding access to mental health support during pregnancy. However, there were some aspects of maternity care where people report a poorer experience and where analysis indicates a longer-term decline in positive feedback over time, including communication during labour and birth, information provided during care in hospital after birth and involvement in postnatal care.
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Awareness Days
International day of the Midwife, Monday 5 May 2025
World Patient Safety Day, Wednesday 17 September 2025
Baby Loss Awareness Week, 9 - 15 October, 2025
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