This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2021/22, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken.
Highlights from the HSIB report
- The maternity investigation programme has completed 706 reports during 2021/22.
- There has been a 9 percentage point reduction in the number of babies with an abnormal MRI or evidence of neurological damage, from babies referred in 2020/21 compared to 2019/20 (where consent to access medical records was given).
- Over the last year HSIB has made more than 1,740 safety recommendations to trusts addressing a wide range of issues.
- HSIB contacted all families who agreed to do so. However, in 7% of all cases that met HSIB criteria during 2021/22, the families did not agree to any contact being made by HSIB. Therefore HSIB were unable to speak to these families. A further 7% when contacted declined an investigation.
- HSIB has translated information into 31 languages to support families to make an informed choice about being part of the investigations.
- HSIB has implemented a race equality group to develop a considered approach to the use of our demographic data and to help learn how race impacts on people’s lives, experiences and outcomes.
- HSIB has developed an approach to maximise the inclusion of families in investigations. HSIB engages with them at the beginning of an investigation and at significant points during the process to try and understand any needs they may have with regards to communication, health and wellbeing, or day-to-day life.
- HSIB has developed the information it share with trusts to ensure that immediate concerns and emerging themes are shared with them. Trusts receive regular updates on investigations being undertaken and quarterly information to share with their executive boards and frontline staff.
- Quarterly review meetings with trusts continue to see improved attendance from perinatal teams, with maternity board-level safety champions increasingly being in attendance and supporting the frontline teams.
- HSIB has introduced a newsletter to support trusts to share the improvements they have made in response to safety recommendations. This is providing learning opportunities across England and beyond.
- HSIB has piloted work with trusts to develop a Maternity Quality Matrix to provide each trust with insight into their HSIB maternity investigations over time. HSIB plan to roll this out during 2022/23.
- HSIB received feedback from trusts about our investigations and have developed a Maternity Quality Improvement Team to make sure it continues to learn and improve investigations and the processes that support them.
- During investigations HSIB gathers ‘soft intelligence’ relating directly or indirectly to an investigation. This is captured in the maternity observational diary. The diary supports feeding back areas of good practice to trusts and further information relating to the ongoing challenges trusts are experiencing.
- HSIB teams are working with system-level leaders to provide feedback and thematic learning from our investigations.
- During the COVID-19 pandemic, HSIB has continued to work with families and trusts to make sure all communication has been adapted to support families’ wishes.
- HSIB has responded to trusts’ requests to reduce the burden of work required and work collaboratively to ensure investigations are completed.
- The maternity team was part of two live webinars: a joint webinar with the national investigation team in collaboration with ambulance trusts, and a maternity-led webinar entitled ‘Who, what and why?’ which provided information and support for doctors in training.