HSIB reviews a year of 760 maternity investigations

Healthcare watchdog, the Healthcare Safety Investigation Branch (also known as HSIB), has published its 2020/21 maternity programme review. The report looks back on the work that HSIB has carried out to investigate patient safety incidents arising from NHS maternity care in England, the themes it identified and its ongoing contribution towards improving safety for women and their babies around the time of birth.

What is HSIB?

The Healthcare Safety Investigation Branch (HSIB) began carrying out safety investigations in NHS maternity services in England in April 2018. By April 2019, the HSIB maternity programme was fully established in all 130 NHS trusts and 11 ambulance services which provide or support maternity services in England.

HSIB investigates maternity safety incidents which meet certain criteria set out by RCOG’s Each Baby Counts programme and MBRRACE-UK’s national maternity healthcare programmes. These include stillbirths, neonatal (newborn baby) deaths or brain injuries to babies diagnosed within the first week of life, and maternal deaths in pregnancy, during childbirth or within 42 days after the end of the pregnancy (excluding accidental causes and suicides).

Since the beginning of the COVID-19 pandemic, HSIB no longer routinely investigates cases relating to babies who show no apparent signs of brain damage after cooling. However, they may decide to investigate such cases on an individual basis if a family or NHS trust reports concerns about the maternity care.

All eligible maternity safety incidents involving the brain injury of a baby or the death of the mother or baby, are referred to HSIB by the NHS trust where the incident took place. Since COVID, it is up to HSIB then to assess whether the baby has been harmed before deciding whether the case should be passed on to NHS Resolution for early notification. Where an incident meets HSIB’s criteria, HSIB’s investigation replaces the trust’s own local investigation.

HSIB say that their investigations ‘deliver a standardised, learning-orientated, and person-centred approach to safety investigations that produce insight to help reduce maternity safety incidents across the NHS’. Their investigations identify factors that may have contributed towards a death or injury, based on interviews with the family and hospital staff. They identify themes to help the NHS learn from mistakes and make safety recommendations to improve maternity care both in the trust where the incident took place and nationally. Where a patient’s care has been investigated, the investigation report is shared with the family. HSIB reports can be provided in different languages and formats to meet the family’s needs. The report is also shared with the NHS trust where the mother or baby’s maternity care took place, which is responsible for carrying out any safety recommendations in the report.

Statistics from HSIB’s maternity investigation programme 2020/21 review 

Between April 2020 and March 2021 HSIB completed 1,024 reports into baby brain injuries, stillbirths and newborn or maternal deaths. During the same period of time HSIB received 1,269 further referrals for maternity investigations from English NHS trusts.

509 of these referrals didn’t proceed to HSIB investigation for reasons which included duplicate referrals (170), refusal of consent to access medical records (124),  or cases not meeting HSIB’s referral criteria (80). 135 maternity safety incidents which would previously have been eligible for investigation were excluded as a result of HSIB’s COVID-related decision not to investigate cooled babies without apparent signs of brain injury. 

HSIB accepted 760 referrals for investigation. 381 of these investigations had been completed by March 2021, with a  final report provided to the family and the trust. 96% of these were completed within six months. The remaining 379 investigations are still ongoing.

The cases included:

• 66 cases where the mother had died (maternal death);
• 101 newborn babies who had died (early neonatal deaths);
• 147 babies who were stillborn (having been healthy at the start of labour);
• 446 babies who were cooled or diagnosed with brain injuries.

HSIB noted that it had observed an increase in stillbirth and maternal death referrals at the start of the pandemic and have already published a national investigation report highlighting the patient safety risks and themes from their review of maternal deaths during the first wave of the pandemic.

In addition to investigations into individual cases of harm, HSIB’s maternity programme published four national learning reports in 2020/21:

• Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection;
• Neonatal collapse alongside skin-to-skin contact;
• Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia;
• Maternal death: learning from maternal death investigations during the first wave of the COVID-19 pandemic.

Themes highlighted by HSIB’s maternity programme 2020/21

According to HSIB’s maternity programme 2020/2021 review, HSIB made over 1,500 safety recommendations to NHS trusts arising from their maternity investigations. Common and frequently recurring maternity safety themes included:

• escalation of safety concerns about mothers and babies, with issues relating to:

• concerns about a mother or baby not being effectively communicated to more senior or specialist clinicians;
• responses to escalation which don’t bring about change in a mother’s or baby’s clinical condition;
• whether escalation happens at the right time;
• the environment and trust culture in which care is given;
• anticipating (rather than just reacting to) events;
• communication within and outside the clinical team.

• clinical oversight, including issues relating to:

• multi-disciplinary team-working (different specialists or types of clinicians working together);
• the need for a named consultant to take overall responsibility for the care of a mother with complex needs;
• accurate and timely assessment, decisions and communication relating to a mother’s risk status;
• ensuring that detailed medical records are accessible in emergency situations or when the mother changes location, care team or treatment pathway.

• clinical assessment and monitoring, including issues relating to:

• recognising when an unborn baby is not growing properly and planning for the needs of babies who may be born small for dates or large for gestational age;
• recognising and providing proper advice, care and fetal monitoring when a woman is in established labour;
• shortage of beds on the labour ward;
• providing 24 hour a day triage services, staffed by dedicated skilled clinicians with access to mother’s records.

• the impact of inconsistent or conflicting local and national clinical guidelines on maternity staff’s ability to provide safe care:
• the impact of care which crosses different healthcare boundaries, such as lack of communication between different trusts or where the ambulance service involved in the woman’s care.

Can HSIB really claim to be making a difference?

Improvements in maternity safety incident investigations have long been overdue. Historically, NHS trusts have had neither the skills nor the candour to investigate, share the lessons and learn from their mistakes. Whilst HSIB’s approach has undoubtedly provided eligible injured and bereaved families with a more professional standard of investigation, its current impact on maternity safety is arguably little more than a drop in the ocean.

HSIB’s review tells us that its investigations and recommendations are positively influencing safer maternity care, with benefits including improvements to the NHS’s safety culture, staff freedom to speak up and patient engagement and trust in the fairness of their investigation. However, we also hear that whilst most trusts welcome HSIB’s reports and respond to their recommendations, others have taken longer to recognise or prioritise the actions needed to deal with risks and sometimes solutions do not appear to be easily achievable. On occasion, HSIB has needed to escalate its own concerns to relevant regulatory agencies where it has evidence that risks are persisting.

Meanwhile, the Parliamentary Health and Social Care Committee inquiry into maternity services, which HSIB mentioned in its review, found that families still do not receive the support they deserve after maternity safety incidents. It acknowledged HSIB’s role in maternity investigations but found their effectiveness limited by the length of time it takes to produce their reports and by NHS trusts’ failure to act on their recommendations.  

Given the continued, unacceptably high level of severe (and sometimes fatal) injury to mothers and babies, and further hospital maternity scandals reported in the news, it is premature for HSIB to claim that ‘improvement’ has been brought about on the basis of isolated success stories and anecdotal evidence.

The sad reality is that there is little evidence that the NHS is capable of learning from its mistakes. There is also little evidence that injured families are being properly advised to seek independent specialist legal advice or that they have a right to financial help with meeting their considerable needs through compensation.

If you or your child have suffered severe injury as a result of negligent maternity care, you can find out more about making a claim by talking to one of our specialist birth injury solicitors, free and confidentially, by contacting us here.