HSIB maternity investigation programme year in review 2022/23 (3 August 2023)

Summary

This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2022/23. During this period HSIB completed 702 reports and made more than 1,380 safety recommendations.

Content

The report lists the following highlights from HSIB’s maternity investigation programme during 2022/23:

• During 2022/23, the maternity investigation programme completed 702 reports. This was a similar figure to previous years. At any one time there were approximately 355 active investigations.
• The number of investigation referrals relating to brain injury indicate a sustained decrease in babies with abnormal MRI results or neurological damage.
• In the last year, the programme made more than 1,380 safety recommendations to trusts and other healthcare organisations, covering various topics.
• Families remain central to the work HSIB undertake. HSIB contact all families who give their consent; of these 86% agreed to participate and 14% declined further participation in the investigation.
• As part of HSIB’s initial engagement and ongoing communication with families they have been supported with interpretation/translation services on 670 occasions.
• Information provided to families about HSIB investigations has been translated into 36 languages. This helps families to make informed choices about participating in investigations and provides better support to enable their ongoing involvement.
• HSIB’s reports, and those of other organisations such as MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK), have identified racial differences in maternity outcomes. HSIB has formed a race equality group to develop the data from investigations to analyse demographics and understand the impact of racial diversity on experiences, access to care, and outcomes.
• The quarterly review meetings HSIB undertake with trusts have continued to develop with greater engagement from executive-level staff, board-level maternity safety champions, and the frontline perinatal teams. By working closely with trusts, the programme has helped to increase the involvement of perinatal teams in patient safety.
• The programme has deepened the understanding of the role of emerging themes and how they help to identify issues in the healthcare system as a whole that contribute to the harm experienced by pregnant women/people and their families.
• HSIB now publish a national newsletter three to four times a year to support trusts in sharing improvements they have made in response to safety recommendations, providing learning opportunities across England and beyond.
• A Maternity Quality Matrix is being rolled out to trusts to provide insight into their HSIB maternity investigations over time.
• Feedback is received from trusts and the HSIB Maternity Quality Improvement Team continues to improve investigations and support processes.
• During investigations, ‘soft intelligence’ relating to the investigation is captured in a maternity observational diary, which shares concerns as well as good practices with trusts, and information about ongoing challenges.
• Members of the maternity team ongoingly present at regional and national meetings to share their work and findings from reports.