HSSIB Investigation Report: An exploratory review of maternity and neonatal services (19 August 2025)

Summary

This report is a summary of information the Health Services Safety Investigations Body (HSSIB) collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved meetings with 17 stakeholders and a review of 35 safety concerns submitted to HSSIB and one report published in 2021 by the Healthcare Safety Investigation Branch (HSIB), the precursor organisation to HSSIB.

Content

Themes arising from stakeholder interviews identified in this report including:

• Some improved outcomes - some progress has been made in maternity and neonatal outcomes, staffing levels and governance arrangements.
• Complex national infrastructure - national maternity and neonatal systems are overly complex.
• Collaboration and information sharing between national organisations - national collaboration efforts are inconsistent and variable.
• Development, oversight and implementation of recommendations - too many recommendations exist, with limited implementation.
• Local governance arrangements - local governance of maternity services often operates in isolation from the wider organisation
• Risk awareness - services still lack the consistent ability to identify and respond to clinical risks.
• Potential for learning in maternity and neonatal services - there is limited potential to learn from harms that happen to women and babies during pregnancy, labour and birth.
• Compounding patient harm - patients experience compounded harm due to issues within the wider healthcare system, particularly the way local investigations are carried out or the way complaints/concerns are managed.
• Compounding staff harm - staff are also affected by cumulative stress and harm.
• Inequalities - disparities in care and outcomes persist because of health inequalities.
• Training and standards - there are concerns about the standards set in undergraduate and postgraduate education and whether these can be adhered to in practice.