HSIB maternity programme year in review 2020/21 (August 2021)

Summary

This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, 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.

Content

This review covers everything from operational performance to planned developments in the 2021/22. There are key sections on family and NHS staff engagement – focusing on their experiences of working with HSIB including how they gather their feedback and sharing direct quotes. The review also sets out how HSIB fits into the wider maternity picture, explaining the way they work with other organisations and the contributions they have made to high-profile initiatives, projects, inquiries and reports.

Over 2020/21, HSIB maternity investigation reports have contained 1500 safety recommendations to trusts, addressing an array of issues and the most frequent emerging themes. This includes:

• effective escalation of safety concerns about mothers and babies
• clinical oversight
• clinical assessment and monitoring
• use of clinical guidelines influence the care provided
• impact of pathways of care crossing healthcare boundaries.