MNSI Annual Report and Recommendations 2025/26

Summary

The Maternity and Newborn Safety Investigations (MNSI) programme annual report highlights a year of activity aimed at improving maternity and newborn safety for women, babies, and families across England. Between April 2025 and March 2026, MNSI completed 618 investigations and made more than 1,300 safety recommendations.

Content

The most frequent themes in the recommendations made by MNSI for 2025/26 related to:

• clinical assessment

• guidance

• fetal monitoring

• communication

• escalation

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

• launch of MNSI’s two-year programme strategy (2025-27), sharpening its focus on prevention and partnership.

• development of the SPARC coding framework, enabling deeper thematic analysis of investigation findings.

• expansion of the COMPASS pilot, now running across 29 NHS trusts, to capture how organisational culture affects safety.

• continued use of health equity tools (HEART and HEWS), which explored inequalities in 100% of maternal death investigations.