Today (17 September 2025) is World Patient Safety Day. The slogan for this year is ‘patient safety from the start’, focusing on safe care for every newborn and child. World Patient Safety Day 2025 aims to drive meaningful improvements and reaffirm every newborn and child's right to safe and quality care. We asked Sandy Lewis, Director of the Maternity and Newborn Safety Investigations (MNSI) programme and Louise Page, Clinical Director of MNSI for their reflections on why today matters to them.
My interest in patient safety was initiated by Charles Vincent’s work with the Health Foundation. The work summarises that complications in healthcare have historically been accepted as the inevitable consequence of medical intervention. The work describes the changing emphasis on preventable events, highlighting the importance of learning and shifting from an individual focus to consider wider systemic causes.
To work at MNSI and to develop the programme is a privilege. The journey from initially rolling out the programme to where we are now has been a team effort and one I am immensely proud to be a part of. Our ability to inform the national agenda within maternity and newborn safety continues to develop alongside collaborative opportunities to inform the wider landscape. All of this would not be possible without the work we do with families and trusts.
Our family engagement approach and model are nationally recognised and the work our team undertake with families ensures our approach is accessible and representative of their individual needs. The development of COMPASS (Culture of Organisations and its iMpact on PatientS’ Safety – Assessment) is presenting further opportunity to explore the cultural approach to safety investigations within trusts. With the first pilot close to completion, the team are working towards the next pilot, taking forward the rich feedback they have received.
The ongoing development of the programme and working with families and staff to inform safe high-quality care remains central to our work over the next year and beyond.
Sandy Lewis, Director of MNSI
 Sandy Lewis, Director of MNSI
Hearing about James Reason sparked my interest in patient safety during my postgraduate training years in obstetrics and gynaecology:
‘Human fallibility can be moderated but it can never be eliminated … People do not act in isolation. Their behaviour is shaped by circumstances’. (Reason, 1995)
It really switched something in my head and made me think differently about my role as a clinician working in the high-risk world of obstetrics. Safety wasn’t about me being the ‘perfect’ doctor; it was about really understanding the system we work in, our past experiences and how these impact the decisions we make, often at a time critical point in a woman and baby’s care pathway.
This led me to a MSc in Quality and Safety in Healthcare at Imperial College and a consultant post which incorporated my clinical love for maternal medicine and intrapartum care, along with a leadership role in maternity quality and safety.
There are two elements of our work at MNSI that I’m most proud of – our focus on promoting health equity through our Health Equity Assessment and Resource Toolkit (HEART) and Health Equity Warning Score (HEWS) work, and how in recent months we have developed our thematic learning programme to share more insights from our investigations with the wider system.
For the future at MNSI, our bespoke coding system that we have been developing over the last 12 months is going to move our thematic work further forward in leaps and bounds – I look forward to being able to share the outputs of this exciting work in the coming months.
Louise Page, Clinical Director of MNSI
 Louise Page, Clinical Director of MNSI
To learn more about our work to ensure all mothers, birthing people and babies receive safe and quality maternity and neonatal care, you can:
 We are creating an Editorial Board to help shape vital safety communications that make a real difference.
We welcome expressions of interest from a range of stakeholders including families with lived experience, healthcare professionals across maternity and newborn services, royal college representatives, third sector organisations, and NHS bodies who share our commitment to improving outcomes for mothers, birthing people and babies.
This role is voluntary. Register your interest by summarising your experience in 300 words or less. Email this to Sonia Barnfield - Deputy Clinical Director, MNSI and Francessca Scott - Senior Stakeholder Relations Adviser, MNSI by 12:00 midday on Friday 26 September.
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