• To highlight the influence of workplace culture on clinical decision-making and its potential impact on patient safety.
• To demonstrate the roles and responsibilities of senior leaders.
• To emphasise the need for clear and structured communication within the multidisciplinary team (MDT).
• To underline the importance of self-awareness and recognition of personal and professional limitations to reduce the risk of harm.
• To understand the role of clear, well-defined escalation pathways in supporting timely senior involvement and safe clinical care.
• To highlight importance of undertaking a holistic maternal assessment. 

• Safer assisted vaginal births – Ensure all obstetricians are trained on the basic principles of assisted instrumental delivery, including avoidance of excessive force so that gentle traction is applied with a uterine contraction and appropriate use of ventouse and forceps with episiotomy when required. This should also include how to assess for OASIs.
• Supervision of trainee clinicians – Provide adequate support and supervision of both midwives and non-consultant grade doctors when performing complex deliveries such as assisted births, particularly rotational deliveries. Promote and encourage perineal protection, especially during difficult deliveries.
• Diagnosis of OASI – Focus on appropriate clinical training to ensure clinicians can perform a systematic bimanual vaginal and rectal examination to identify an OASI. This should include using the pill rolling technique to identify OASI at the time of birth so that the injury can be repaired, as this gives the best outcomes.
• Education – Educate clinicians on the symptoms that can affect women who sustain OASIs, as well as the social, psychological, and economic impact of these injuries. This includes supporting clinical teams to consider underlying risk factors during pregnancy, follow the appropriate pathway of assessment, and escalate concerns about potential OASIs, supported by greater awareness of the significant impact these injuries can have on women. We must also ensure that clinicians are appropriately trained and supervised to repair OASIs.
• Awareness of rectovaginal fistula (an undetected or repaired fourth degree tear) – This remains a rare complication of OASIs but has a devastating impact on women. Clinicians should be aware of this potential complication, its presenting symptoms, and how to assess for this in a multidisciplinary context.
• Pathway for management of women with missed OASIs – Management remains very variable across units, depending on local facilities and expertise available, and further guidance is urgently needed to improve consistency and long-term outcomes.

NHS Resolution have also produced a one page poster that summarises the key messages at a glance which clinicians are encouraged to print and display this poster on notice boards within clinical areas. You can find this here.

The report summarises its key points as follows:

• 120 Trusts submitted for MIS Year 6.
• MIS payments into the scheme ranged from £140k to £3.86 million.
• 102 Trusts achieved full compliance (10/10) after validation – the highest since the scheme began.
  • No Trusts were downgraded following external verification suggesting improved data integrity and/or supportive validation processes.
  • 18 Trusts were upgraded following external verification.
  • Trusts appear to have improved openness in self-declaration.
• Safety Action (SA) 8 (Multi-Professional Training) had the lowest compliance, often due to incomplete training coverage across all required staff groups. Challenges with anaesthetic and obstetric compliance.
• SA1 (Perinatal Mortality Review Tool [PMRT]) continued to be a challenge for some Trusts, with delays in completing factual questions and lack of evidence of multidisciplinary review within expected timeframes.
• SA2 (Maternity Services Data Set [MSDS] submission) achieved 100% compliance, reflecting strong engagement with national data requirements.
• All non-compliant Trusts in Year 6 submitted fully costed and sustainable safety improvement plans. Implementation will be overseen by Integrated Care Boards (ICB).
• Four appeals were submitted by Trusts in relation to their compliance outcomes.
  • One appeal was upheld, resulting in a change to the Trust’s compliance status.
  • Three were not upheld as the original decisions were found to be consistent with the standards and evidence.

• NHS Resolution received 14,428 new clinical negligence claims and reported incidents in 2024/25.
• £3.1 billion was paid out in 2024/25 for compensation and associated costs on all of NHS Resolution’s clinical schemes, compared to £2.8 billion in 2023/24.
• £1.3 billion of the total clinical negligence payments in 2024/25 related to maternity.
• The estimated ‘annual cost of harm’ for incidents in 2024/25 for the main clinical scheme, Clinical Negligence Scheme for Trusts (CNST), was £4.6 billion.
• NHS Resolution’s provision for future liabilities as of 31 March 2025 was £60.3 billion.

• 17,116 clinical and non-clinical claims were resolved in 2022/23 compared with 16,484 in 2021/22.
• The total number of new clinical negligence claims and reported incidents across primary and secondary care reached 13,511, which was 1,567 less than the previous year.
• Clinical claims received (Clinical Negligence Scheme for Trusts and Clinical Negligence Scheme for General Practice) increased by 1,019 claims, or 8.6%. The volume of non-clinical claims reported in 2022/23 is comparable to 2021/22 although remains lower than pre-pandemic levels.
• Payments against all NHS Resolution clinical schemes for 2022/23 were £2.73 billion (£2.4 billion in 2020/21) in total – which comprised damages paid to claimants of £1,992 million (£1,775.3 million in 2021/23), claimant legal costs of £490.9 million (£470.9 million in 2021/22) and NHS legal costs of £158.8 million (£156.6 million in 2021/22).
• In 2022/23 the ‘annual cost of harm’ for CNST was £6,278 million. This is a decrease of £7,007 million compared to the previous year (in 2021/22 the cost of harm for CNST was £13,285 million). The decrease is primarily due to the change in His Majesty’s Treasury (HMT) discount rates which has had the effect of significantly reducing the value of claims. If HMT discount rate changes for 2022/23 were not applied, the equivalent cost of harm for CNST for 2022/23 would have been £12,631 million.
• NHS Resolution published six thematic reviews on claims concerning emergency medicine, complications of the lower limb in diabetes, General Practice and Early Notification Scheme.
• NHS Resolution held an in-person national maternity conference attended by 215 delegates (including 77 trusts) aimed at sharing the experiences of families, maternity units and maternity safety experts.

1. Deliver the next phase of our strategy to move claims, concerns and disputes into a neutral and less adversarial space
2. Further develop our new indemnity schemes (for general practice and Covid-19) while using our expertise to support wider improvements, including how healthcare-related claims are managed
3. Build on our unique role in sharing learning from claims and concerns back to the health system, in particular in relation to the interplay between general practice and secondary care and how to respond when harm occurs 
4. Responding to the changing health landscape including reviewing our indemnity scheme pricing and the role of incentives in light of wider system changes
5. Develop and support our people through a period of significant change, building on our Investors in People accreditation, including a renewed focus on equality, diversity and inclusion 
6. Make a step change in our technology and data analytics capabilities and infrastructure

The report also outlines NHS Resolution's strategic priorities for 2022-25:

1. Deliver fair resolution
2. Share data and insights as a catalyst for improvement
3. Collaborate to improve maternity outcomes
4. Invest in our people and systems to transform our business

Results

The results are split into two parts. The first part analyses the problems identified from the clinical details of each claim and the second part analyses the quality of the serious incident reports.

Part one identifies recurring clinical themes and areas for improvement. Five areas where there were common issues in clinical care are discussed in depth:

• substance misuse
• communication, particularly failures in intra-agency working
• risk assessment
• observations
• prison healthcare.

Part two identifies four main areas of concern, where:

• There was a lack of family involvement and staff support through the investigation and inquest process.
• The quality of root cause analysis undertaken as part of the Serious Incident (SI) investigation was generally poor and did not focus on systemic issues.
• Due to the poor SI report quality, the recommendations arising from SI investigations were unlikely to reduce the incidence of future harm.
• Reports to prevent future deaths (PFDs) were issued to trusts by the coroner with little consistency and there were poor mechanisms to ensure that changes in response to the PFDs had been made or addressed the issues highlighted.

Key learning points:

• As soon as a patient attends hospital to seek medical attention there is a duty of care owed to them.
• Patients attending maternity should be provided with reasonably accurate information regarding waiting times for assessment.
• Maternity receptionists should have the appropriate training and local induction to ensure that accurate information is provided.
• Clinical and non-clinical staff should be aware of the standard for triage waiting times, ensure that accurate information is communicated and also be aware that the information they provide may influence the way patients access clinical care.