The leading body for maternity and newborn safety investigations in England

September 2026

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

In this edition:

• Publication of our new national learning report: Learning from investigations where intrapartum care has been given at home
• New blog: What the Amos and Ockenden reviews mean for maternity and newborn safety
• Update on COMPASS pilot
• New blog: Review of the RCOG's new scientific impact paper
• Safety spotlight: Caring for pregnant women on non-maternity hospital wards

New national learning report published: Learning from investigations where intrapartum care has been given at home

We are pleased that our new national learning report has been published: Learning from investigations where intrapartum care has been given at home.

The report provides a series of safety prompts for NHS trusts on topics such as staffing availability, training and guidance, and communications between different care professionals.

Rebecca Daniels, Midwifery Lead Clinical Advisor at MNSI and co-author of the report said: "We looked at 59 investigations over seven years. In each investigation, staffing challenges or delays in recognising emerging risks were contributing factors. This is not about discouraging home births. It is about ensuring home birth services have appropriately skilled midwives, sufficient support, and systems that enable teams to respond quickly when a woman’s or baby’s needs change."

We hope that the review’s findings will inform and support other national work, led by NHS England, that is developing resources to consistently support commissioners, providers, and women and families, relating to the provision of home birth services.

New blog: What the Amos and Ockenden reviews mean for maternity and newborn safety

The Ockenden Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust and Baroness Amos's Independent National Maternity and Neonatal Investigation both landed in July 2026.  

Together, they set out the clearest picture in years of what needs to change in maternity and newborn care.

Our Clinical Director, Louise Page, wrote a two-part blog series about what these findings mean for the way we care for women, babies and families. Louise emphasises that progress in maternity and newborn care should not only be demonstrated on paper. It should be felt directly by women and babies, particularly for those communities who continue to be disproportionately affected by inequalities.

Update on COMPASS pilot

Thank you to the 28 trusts who have participated in our second COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) tool pilot. We are now analysing the findings from our 370 observations, with nearly 50% of these being positive safety observations. In the autumn, we will share the findings with each individual trust and ask for their views on the tool. In 2027, we hope to be able to share the COMPASS tool more widely and use our findings to shape national policy.

New blog: Review of the RCOG's new scientific impact paper

One of our neonatal clinical advisors, Paul Mannix, has written a blog on the recent scientific impact paper published by the Royal College of Obstetricians and Gynaecologists on the care of the umbilical cord and the newborn during the third stage of labour.

The paper explains how delayed cord clamping supports a baby's transition to life outside the womb. Lung inflation, usually triggered by crying, eases pressure on blood vessels and helps the circulatory system adapt. For babies who need help to start breathing, giving inflation breaths with the cord still intact offers similar benefits.

 In MNSI investigations, we see variations in cord clamping practices during neonatal resuscitation. Paul encourages teams to discuss the paper and consider how it might shape their own practice.

Safety spotlight: Caring for pregnant women on non-maternity hospital wards

Our September safety spotlight focuses on caring for pregnant women admitted to non-maternity hospital wards.

This safety spotlight arose from an investigation where a woman in her third trimester was cared for in the surgical area of the hospital following a non-pregnancy related surgical procedure. She went into labour but there were delays in recognising this, and the baby died before birth.

We have posed two safety prompts around nursing staff training and joint care planning.