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The leading body for maternity and newborn safety investigations in England |
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- Our strategy
- Editorial Board
- Safety spotlight
- Personalising our investigation reports
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Last December we launched our strategy, a renewed commitment to preventing harm, reducing inequalities, and ensuring that families’ voices shape maternity and newborn safety.
Building on insights from more than 4,300 investigations, we will strengthen our analytic capabilities to identify emerging risks earlier and support NHS trusts to take action before harm occurs.
A key focus is ensuring that improvements reach the communities who need them most, including Black and Asian families, who continue to face the poorest maternal and newborn outcomes.
Catch up on our strategy here.
 We’ve launched an Editorial Board to strengthen the quality and consistency of our publications. Comprising of 12 professionals from maternity, neonatal, legal, and healthcare sectors, the Board will review content before publication. This collaboration enhances stakeholder engagement and ensures we are upholding the highest standards in the clarity, accuracy, and accessibility of our publications.
Read more.
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Safety Spotlight: Late diagnosis in breech presentation
We have completed a number of investigations where there has been a late diagnosis, in established labour, of a baby being in breech presentation during an induction of labour.
Consider the following prompts for your trust:
- Are additional checks, such as a presentation ultrasound scan, routinely undertaken before induction of labour to confirm a baby's presentation?
- Does your local guidance include a pre-induction of labour checklist?
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- Do all relevant areas, where induction of labour is commenced or continued, have access to portable ultrasound machines?
- Is there a training programme or competency assessment in place for staff who perform presentation ultrasound scans and how is ongoing competency assured?
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Since April 2024, families have been offered the opportunity to include the mother’s and/or baby’s name in our investigation reports and to add a personalised section. This reflects PSIRF principles and national best practice. Personalisation helps humanise reports, supports compassionate engagement, and reduces ongoing psychological harm.
As part of our ongoing commitment to supporting trusts and families, a standard operating procedure has been developed to provide a clear and consistent approach to personalisation, while also safeguarding the psychological safety and wellbeing of staff. To prepare staff, maternity investigators inform them during interviews that the report may include the mother and/or baby’s name and an ‘About [Name] section’. A templated letter sent with a draft report also reinforces the trust’s responsibility to recognise and provide ongoing support for the wellbeing of staff.
Clear processes are in place for trusts to raise concerns about the use of names or the ‘About [Name] section’. This ensures we are being balanced and fair, taking into account both family wishes and trust considerations.
Read more.
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