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New way of investigating maternity incidents completes NHS rollout

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From this week, all 130 trusts in England should be referring maternity cases involving intrapartum stillbirth, early neonatal deaths and severe brain injury to a new independent agency set up to investigate patient safety incidents.

Since 1 April 2018, the Healthcare Safety Investigation Branch (HSIB) has been responsible for any investigations of maternity incidents that meet the criteria for the Each Baby Counts programme.

“The year ahead will enable us to stabilise the programme and start drawing out the key areas of learning”

Jimmy Walker

The first team of six maternity investigators started training in April 2018 and the first trusts started referring cases in May 2018.

HSIB said it had now recruited and trained over 140 investigators and team leaders, clinical advisors and specialist advisors to help scope investigations, analyse findings and make recommendations.

By the end of March, it is estimated that there will be 400 live cases, with around three new referrals coming in every day.

For maternity incidents, the HSIB’s investigation replaces the local investigation, although the trust remains responsible for duty of candour and for referring the incident.

HSIB’s reports and safety recommendations are sent directly to the families and the trust.

The rollout has been split into regions. The South (three teams), Midlands and East (four teams), London (three teams) and North (four teams).

There was “no particular order” to the rollout other than being done on a region by region basis, noted the HSIB.

Professor Jimmy Walker, clinical director of maternity investigations, said: “The rollout of the maternity investigation programme across so many trusts has been an ambitious and exciting challenge which we are proud to have delivered.

“It has been possible due to the dedication and hard work of our teams, as well as fantastic support from trusts, staff and the families,” said Professor Walker.

“We are beginning to see, understand and develop some of the main themes that will help us to prevent a recurrence,” she said. “The responses to our reports and feedback have been positive and we are already seeing signs of beneficial change.

“The year ahead will enable us to stabilise the programme and start drawing out the key areas of learning whilst understanding how we can share this back across the NHS and influence the care families receive,” she added.

A key highlight of the programme has been HSIB’s innovative family engagement model, with investigators working closely with the body’s expert lead in the area, Louise Pye.

As a result, over 97% of families have agreed to be involved in the investigations.

Sandy Lewis, director of maternity investigations, said: “Working effectively with the families involved has been a huge priority for us.

“We are very grateful to the families who have allowed us into their lives at such a difficult time and with whose consent we are able to function.

“We also thank trusts and their staff, who have been positive and engaged throughout investigations.”

In November 2017, the government published a refreshed National Maternity Safety Strategy Safer Maternity Care that included plans for HSIB to undertake around 1,000 independent safety investigations.

The government’s announcement looked to fulfil a recommendation from the Morecambe Bay inquiry, which called for “clear standards” for investigating maternity incidents including independent scrutiny.

The HSIB will investigate cases of intrapartum stillbirth, early neonatal deaths and severe brain injury diagnosed in the first seven days of life, when the baby:

  • was diagnosed with grade III hypoxic ischaemic encephalopathy (HIE)
  • was therapeutically cooled (active cooling only)
  • had decreased central tone and was comatose and had seizures of any kind

It will also investigate direct or indirect maternal deaths in the perinatal period.

The HSIB began operating on 1 April 2017, offering an independent service for England, and with a brief to guide and support NHS organisations on investigations, and also to conduct safety investigations.

 

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