• How does your service record that a woman has a learning disability and how it affects her day-to-day care needs?
• What are the barriers to offering every woman with a learning disability the opportunity to complete a health and care passport?
• Could tools such as the health and care passport be used more routinely to capture communication preferences, concerns and support needs?
• How does your service ensure key information about learning needs and social complexities are consistently shared in discharge summaries?
• Have your staff been supported to undertake the government approved Oliver McGowan mandatory training on Learning Disability and Autism?

The new MNSI safety briefing draws on what we have learned through our investigations and aims to support the safe care of babies undergoing cooling in maternity and neonatal settings.

The briefing shares our evidence and insight on this topic and provides prompts for maternity and neonatal providers to consider:

• Whether local guidance on cooling aligns with national guidance, including when to commence passive cooling and the use of rectal temperature probes.
• Whether staff have the training and equipment they need to initiate cooling safely and consistently.

We conduct independent safety investigations into maternity and newborn events. We listen to and learn from families and healthcare professionals, and we work in partnership to prevent future harm and improve care.

MNSI's Vision

A safer future for maternity and newborn care built on listening and learning through independent safety investigations.

MNSI's Strategic Priorities 2025-2027

1. Excellence - We will strengthen MNSI’s foundation by improving governance, developing our analytical capacity and supporting our people, while maintaining the investigation quality that underpins our credibility. This focus ensures we can respond effectively to evolving safety challenges and take on an expanded role.
2. Impact - Building on our investigatory experience, we will support the national system in identifying and reducing maternity and newborn safety events before they occur. By harnessing predictive intelligence and proactive safety insights, we will enable NHS trusts to anticipate  and prevent future harm, while continuing to develop robust ways to demonstrate MNSI’s impact across the healthcare system.
3. Relationships - We will build meaningful partnerships with families, healthcare professionals and system partners to drive sustained improvements in safety and equity, ensuring that all communities benefit.

The most frequent themes in the recommendations made by MNSI for 2024/25 related to:

• clinical assessment
• escalation
• guidance
• clinical oversight
• communication.

The report also highlights improvements and innovations in how MNSI shares learning, including:

• A new report style designed to be clearer for families and trusts.
• Introduction of safety prompts, giving trusts practical questions to improve local practice.
• Pilot and development of the COMPASS tool to capture cultural issues influencing safety.
• Embedding of health equity tools (HEART and HEWS) into all new investigations to ensure inequalities are systematically addressed.

The Annual Report also shows strong engagement from healthcare staff and families. 95% of trust staff said MNSI’s investigation process was clear, while 86% agreed the programme is improving safety and culture. Families described feeling listened to and valued, with many reporting that MNSI’s investigations gave them answers and reassurance they would not have otherwise received.

MNSI will build on this work in 2025/26, expanding its thematic learning through new coding systems and AI-supported analysis, while continuing to share learning nationally and internationally.

Priming the infusion line took much longer than expected; visually blood was seen moving through the line which gave reassurance that the equipment was working as intended. During the procedure the volumetric infusion pump showed that the expected volume had been infused, which meant staff were not alerted that the baby was not receiving sufficient blood until after their condition deteriorated.

• Does your local process ensure a repeat bilirubin is measured before starting the exchange transfusion to ensure that it is still required?
• Are all staff aware that infusion lines differ and know about the different filter characteristics?
• How are staff supported to recognise different infusion lines?
• Where equipment is collected into ‘packs’ for a procedure, how does the trust ensure the correct equipment is included?
• How do staff, of all levels of seniority, recognise and seek help when events are not progressing as expected? For example, how long the infusion line should take to prime and when should this trigger a review of the equipment being used?
• Does local simulation training include the use of the incorrect infusion line with expired blood, to demonstrate the impact of this on the procedure?
• How does the local system of recording and overseeing a baby’s observations support staff to recognise changes in their condition during the exchange transfusion?
• Does your local process for exchange transfusion include a role, focussed on oversight of the transfusion, to help recognise and respond to any deterioration, including stopping the procedure?

This equipment issue has been reported to the MHRA via the Yellow Card scheme, in accordance with regulatory requirements for medical device safety.

Why was COMPASS developed?

COMPASS was created based on work carried out by the Patient Experience Library who conducted a literature review of over 10 years’ worth of avoidable harm enquiries, which included the reports on the maternity services at East Kent and Morecambe Bay. The work has been collated into a report called ‘Responding to Challenge’¹.

The review demonstrated that poor organisational culture is a recurrent theme in avoidable harm, with significant impact on patient safety. Their work highlights how organisational culture remains challenging to quantify and articulate which hampers external bodies’ ability to provide insight to providers.

Through our safety investigations it became evident that MNSI did not have a way to record and analyse cultural observations in a structured and evidence-based format. This inhibited us from feeding back our observations to organisations to help them see how their organisational culture might be impacting on patient safety.

What are the aims of COMPASS?

We developed COMPASS for two key reasons:

• To provide MNSI staff with a standardised process to record observations around organisational culture, empowering MNSI staff to articulate their observations to trusts in a structured and evidence-based manner rather than based on personal experience or individual interpretation of certain situations.
• To highlight to trusts areas where their organisational culture is contributing positively to patient safety, and areas where enhancing their focus will support and improve safer care to be delivered.

There is already significant work being done to help trusts to improve culture and leadership within maternity services, and COMPASS is a tool designed to complement this by focussing on how organisations respond to and learn from patient safety events.

How is COMPASS being used?

COMPASS is currently being piloted in partnership with 12 NHS trusts in England and is due to finish at the end of May.

MNSI staff are using COMPASS to gather observations about organisational culture that may have impact on patient safety, in a structured manner that reflects the findings from the ‘Responding to Challenge’ report.

The findings are then collated and reviewed to determine how frequently these types of observations are occurring so we can assess the overall level of impact to patient safety that may be occurring within each of the specific areas.

These findings are then shared with trust leadership teams to flag areas that may require attention or focus to improve safety and organisational culture and also highlight observations of culture that have had a positive impact on patient safety.

What is next for COMPASS?

After the pilot, and with the help of feedback from both MNSI staff and trusts who piloted the report, we hope to:

• Adapt the COMPASS tool to match the needs of both MNSI and organisations we work with to maximise the impact of the tool.
• Showcase the positive impact COMPASS has had on patient safety within maternity and newborn services.
• Share our learning through the development of COMPASS and explore how this can be utilised in other sectors to improve patient safety across healthcare.

If feedback suggests that the tool is of value to both MNSI and trusts, we may seek to use COMPASS on a regular basis to help share our insights into organisational culture with trusts to help improve patient safety.

How can people find out more?

• Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety 
• MNSI has launched a new patient safety tool COMPASS 
• Red Flag Tracker – a tool to help recognise the red flags for harmful healthcare cultures by the Patient Experience Library

References

1.      The Patient Experience Library's Responding to Challenge report April 2025

Do you have a safety tool or project to share?

Are you implementing a change that has had a positive impact on patient safety? Could you share your insights, tools and knowledge to help others? Or perhaps you are at the start of the journey, seeking ways to address a patient safety issue that you've identified. Comment below (sign up for free first) or contact our editorial team at content@pslhub.org to tell us more. 

Maternity providers can discuss and explore with their teams what support is available when someone decides to give birth outside of guidance. These ‘safety prompts’ will help facilitate those conversations.

Safety prompts

1. Do you have a guideline or process to support staff and mothers / birthing people when care choices are outside of national or local guidance?
2. Is there any training available for staff in how to navigate conversations in order to facilitate supported decision making?
3. Can women / birthing people benefit from birth choice clinics that are multi professional and use supported decision-making principles?
4. When a woman / birthing person requests a birth plan that deviates from national or local guidance, is this agreed in advance of birth? Do discussions include contingencies so there are clear parameters for acceptable care pathways when the situation changes, or an emergency occurs?
5. Are there resources (leaflets/videos/infographics) available that include up to date information, that are easily accessible and clear, to assist mothers / birthing people in supported decision-making when seeking care outside of national or local guidance?
6. Have you considered exploring with families their reasons for choosing to birth outside of guidance to enable learning?

• Work demands and capacity to respond – the number of tasks needed to be done and whether there are enough (and suitable) staff, and appropriate physical space, to do them.
• Intermittent auscultation – a method used to assess a baby’s heart rate as an indicator of their wellbeing.
• How prepared an organisation is for predictable safety-critical scenarios, and the role played by in situ simulation (a training method that involves staff rehearsing scenarios in the workplace).
• Telephone triage – the assessment a midwife carries out when a pregnant woman telephones because they have gone into labour or have a concern about their pregnancy.