MNSI Annual Report and Recommendations 2024/25

Summary

The Maternity and Newborn Safety Investigations (MNSI) programme has published its Annual Report 2024/25, highlighting a year of activity aimed at improving safety for women, babies, and families across England.

Content

Between April 2024 and March 2025, MNSI completed 613 investigations and made 1,122 safety recommendations to 126 healthcare organisations.

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.