The leading body for maternity and newborn safety investigations in England

July 2026

A monthly bulletin for stakeholders, clinical and non-clinical staff working in maternity and neonatal care and patient safety. 

In this edition:

• Our responses to the latest maternity and neonatal reviews
• Update on our draft report review pilot
• Briefing paper: Remote hospital working
• Safety spotlight: Calling for help in obstetric cardiac arrests

MNSI responds to two major reviews of maternity and neonatal care

The recent publication of Donna Ockenden's Independent Review of Maternity and Neonatal Services at Nottingham University Hospitals NHS Trust, and Baroness Amos's Independent Investigation into Maternity and Neonatal Services in England, is a significant moment for maternity and newborn safety.

Both reviews reflect what we see in our own reports. Delayed escalation. Workforce pressures. The impact of health inequalities. Families not being listened to and not being acted on when they speak up.

Responding to both publications, Sandy Lewis programme director said:

“As a system we now need to work together to ensure trusts and frontline maternity and neonatal staff have the resources to implement change that will mean safer maternity and newborn services for all women, babies and their families.

We are part of the Maternity and Neonatal Taskforce, sitting on an expert reference group to support the implementation of recommendations from both reports, drawing on our insight and expertise from our own investigations"

You can find our responses to each review on our website:

Update: Draft report review pilot

At the start of 2026 (January and February), we trialled a pilot of a new process for sharing draft reports for comment, now called the draft report review. This process was previously known as the factual accuracy check. 

The new process involved sharing draft reports with families and care provider organisations at the same time. During the pilot, we gathered feedback from families, care provider organisations, and our maternity investigators, which has informed our evaluation of the process.

Feedback was largely positive, highlighting the importance of transparency and the role of the process in building trust by offering greater equity. Some concerns were raised about how changes between draft and final reports may be perceived. We also heard that the feedback forms for families were not as accessible as they should be.

Over the coming months, we will continue to develop the supporting documents for this process. These will help prepare families for potential changes to reports by clearly explaining the review process. This work is being undertaken with the intention of launching the new draft report review process in the autumn. We will write to trusts in advance of the launch with further information.

We’d like to thank everyone who has contributed and provided feedback and suggestions for improvement. These will continue to inform the ongoing evaluation and development of the draft report review process.

Briefing paper: Remote hospital working

This month, we have published our next briefing paper on maternity and neonatal care in remote hospitals. A review of 109 MNSI completed investigations between 1 April 2018 and 31 March 2025 found that geographical remoteness led to a complex operational environment and a coordinated approach was needed to ensure safer maternity and neonatal care.  

Key concerns included a lack of joined up multidisciplinary team working, low staff retention and recruitment, limited access to specialist clinical services, and complex emergency transfers affected by weather or ferry schedules.

You can read the paper in full and see what safety prompts we recommended to help open up the conversation between remote and non-remote hospitals to help them work collaboratively

Safety spotlight: Calling for help in obstetric cardiac arrests

Our July safety spotlight focuses on recent investigations where we have found delays in calling the full emergency team and problems accessing maternity areas during obstetric cardiac arrests.

We pose a range of safety prompts that you should consider to ensure timely support during obstetric cardiac arrests.

• Do you have a separate obstetric or maternal cardiac arrest call in your hospital?
• How do call operators at switchboard confirm with ‘2222’ call makers that a recognised emergency call is being made? 
• How do staff know which clinicians will be receiving the ‘2222’ bleep?