HSIB - 731 maternity safety incidents referred for investigation in 2021/2022

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Healthcare safety watchdog, HSIB, has reported on a year of maternity safety incident investigations. The report, HSIB maternity investigation programme year in review 2021/22, looks back at HSIB’s investigations into the deaths of mothers, and the brain injuries and deaths of unborn and newborn babies caused by failings in NHS maternity care from April 2021 to March 2022.

Common safety themes, including failure to escalate, inadequate clinical assessment and oversight, mistakes with fetal heart monitoring, and lack of adherence to guidelines, contributed to the severe harm suffered by pregnant and birthing mothers and their babies. During 2021 to 2022 alone, HSIB investigated more than 700 maternity safety incidents and made 1,740 maternity safety recommendations.

What is HSIB’s maternity investigation programme?

HSIB’s maternity programme investigates maternity safety incidents in NHS trusts in England where a baby at term (more than 37 weeks of pregnancy) suffered:

  • stillbirth – where the unborn baby was alive at the start of labour but was born with no signs of life;
  • neonatal (newborn) death within the first week of life;
  • severe brain injury, diagnosed within the first week of life, and either:  
    • a diagnosis of grade III hypoxic ischaemic encephalopathy (HIE); or
    • was treated with cooling; or
    • was floppy (decreased tone), comatose (unconsciousness) and had seizures (fits).

Since the beginning of the COVID-19 pandemic, HSIB no longer routinely investigates cases where no brain injury is immediately apparent after the baby has been treated with cooling, unless the family or NHS trust ask for an investigation. Where the effects of the child’s brain injury first become apparent at a later stage in the child’s development, the maternity care and circumstances which gave rise to their brain injury are not investigated at that time by HSIB.

HSIB’s maternity programme also investigates maternal deaths, where women or birthing people die during or within six weeks after the end of the pregnancy from any cause related to, or made worse by, the pregnancy or their maternity care.

How many maternal deaths and severely injured babies did HSIB investigate from 2021 to 2022?

From April 2021 to March 2022, HSIB’s maternity programme received 731 referrals for maternity safety investigations. These involved:

  • 433 babies who had been cooled or were diagnosed with severe brain injuries;
  • 51 maternal deaths;
  • 98 neonatal (newborn) deaths;
  • 149 intrapartum stillbirths.

From the eligible cases in which the injured person’s family agreed to HSIB carrying out an investigation, HSIB completed 706 reports.

During the year, HSIB’s maternity programme issued more than 1,740 safety recommendations to NHS trusts addressing a wide range of issues arising from its findings. HSIB makes safety recommendations when it finds failures or concerns which may have contributed to the patient’s injury. It is the NHS trust’s responsibility to take action to address the identified issue and make improvements to prevent similar harm to other patients.

In 7% of all maternity cases that were eligible for HSIB investigation, the families refused consent for HSIB to contact them. A further 7% who were contacted with their agreement later declined an investigation. HSIB says it is working to understand why some families decide not to be involved in an investigation. These efforts include:

  • developing guidance to help the NHS engage with families after patient safety incidents;
  • helping families make informed choices about their involvement and maximising inclusion through:
    • regular contact to establish the family’s needs;
    • translation of information into 31 languages;
    • forming a race equality group to help maximise the use of demographic data and to help HSIB learn how race impacts on people’s lives, experiences and outcomes.

HSIB is also working to ensure that NHS trusts engage with their investigations. Some of the ways they are doing this include updating trusts with information about their investigations and sharing HSIB’s immediate concerns and emerging themes, regular meetings with perinatal teams and safety champions and other feedback and success sharing initiatives such as a newsletter. HSIB plans to help NHS trusts learn from their maternity investigations with the help of a maternity quality improvement team and a maternity quality matrix which will give each trust insight into their HSIB maternity investigations over time.  Additional information about good practise or concerns which comes to light during investigations is noted to support feedback to trusts at a later time.

At regional and system level, HSIB has worked with regional maternity leaders and champions to provide feedback and thematic learning from maternity investigations, provide data about identification and escalation of concerns, and has taken part in webinars to support doctors in training.

HSIB finds ongoing themes in maternity safety investigations

HSIB reported common themes in the areas of concern which led to patient harm during maternity care.

Clinical assessment

HSIB identified failings with clinical assessment, in which the mother and baby’s condition and care needs are assessed, updated and communicated at each contact throughout their maternity care. Accurate, ongoing clinical assessment is vital for correct decision making to ensure that the patient receives safe and appropriate care. Increased use of telephone or virtual assessments during the pandemic prevented clinicians from picking up additional subtle information that can be helpful in a face-to-face consultation. Systems for allowing access to medical records and communicating important clinical information were often not in place, particularly where the patient received care from different specialties, or between primary and secondary teams or maternity and emergency care. Where the mother or baby’s needs changed, such as where an emergency caesarean section was needed, lack of communication and understanding between different clinical teams led to  delays in the emergency response. When mothers accompanied newborn babies who were being transferred to specialist care, there were often failings in clinical assessment of the mother’s continued need for care. 

Clinical oversight:

Clinical oversight, where a senior member of the maternity team maintains a ‘helicopter’ view of the mother and baby’s condition when maternity staff are handling an emergency situation or suffering workload pressures, is vital to ensure correct, timely decision making and safe care. Other clinical oversight failings related to failure to act quickly in response to test or scan results, or lack of face-to-face reviews with the mother or newborn baby by a senior member of the maternity team with overall responsibility for their care.


Escalation involves seeking help or advice from a more senior colleague, and is particularly important when there is an unexpected change or deterioration in the mother or unborn baby’s condition during their maternity care. HSIB found that escalation was hampered by failure to recognise that a deterioration in the patient’s condition requires escalation and call for help, by hierarchical processes within teams, and in cases where the initial response to the escalation was falsely reassuring or not helpful. Lack of communication and inconsistent responses from different hospital departments, such as emergency and maternity departments, often led to delays in recognition and referral for a serious deterioration, and the patient receiving inadequate care.

Fetal monitoring:

Correct monitoring of the unborn baby’s heart rate throughout labour enables the maternity staff to respond quickly to any deterioration in the baby’s condition and ensure that the baby is born before lack of oxygen causes permanent injury to their brain.  Failings included a lack of systematic approach to the interpretation of CTGs leading to misinterpretation of monitoring results, failure to recognise or escalate concerns about fetal monitoring, such as abnormalities in the fetal heartrate on a CTG,  and failure to monitor correctly in accordance with national guidelines. HSIB has asked the Department of Health and Social Care to review how assessment tools for fetal heart monitoring can be improved to reduce the risk of harm to babies.


HSIB found that local (hospital) guidance often doesn’t provide advice on key areas of clinical management, leaving maternity staff unaware of recommended best practise, and affecting patient care. There are also areas where no national guidance exists, and trusts’ own guidance is varied and inconsistent. Lack of resources, equipment and staffing shortages have also led to NHS trusts being unable to implement new guidance in a timely way.

Helping families whose mothers and babies have been harmed by negligent maternity care

HSIB’s maternity investigations review highlights the shocking, unacceptable level of harm that is suffered by mothers, babies and their families as a result of failings in maternity care. Despite HSIB’s valuable work, and many other inquiries and reports, poor escalation, incompetent fetal monitoring, inadequate clinical assessment and oversight are maternity safety themes which result in hundreds of avoidable maternity brain injuries and deaths, year after year. These themes of repeated catastrophic failings have been known by NHS trusts and government for decades.  The longer they remain unresolved, the more families will continue to suffer and be forced to seek legal help to provide for their injured children. 

If you have been contacted by HSIB after the birth of your baby, your child and/or your family may be entitled to substantial compensation if the injuries were the result of negligent maternity care. Boyes Turner’s birth injury specialists have helped countless families obtain compensation to provide for their brain-injured children’s long term needs and rebuild their lives after maternity negligence. You can talk to one of our experienced solicitors, free and confidentially, by contacting us here.

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