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New plans announced for the future of maternity safety investigations
The Secretary of State for Health and Social Care, Sajid Javid, has told Parliament that the government plans to set up a Special Health Authority to continue the work of the HSIB’s maternity investigation programme. The announcement appears to provide some certainty about the future of investigations into maternity care mistakes which result in brain injury to babies, stillbirth, or the death of newborn babies or mothers during childbirth.
The Special Health Authority will run for up to five years so that maximum learning can be achieved from maternity safety incidents involving harm to babies and mothers. It also aims to help NHS trusts gain the expertise, resources, and capacity to carry out maternity safety investigations in the future.
What does this mean for maternity investigations?
According to HSIB’s Chief Investigator, Keith Conradi, HSIB’s two investigation programmes will continue in the future through two separate organisations. The maternity investigations programme will move to the new Special Health Authority. Meanwhile, the national investigations programme, which investigates other types of patient safety incidents, will be carried out by the new Health Services Safety Investigations Body (HSSIB) which will be created by the Health and Care Bill which is currently being enacted by Parliament.
In his announcement to Parliament, the Health Secretary said that the government considers that independent, standardised, family-centred maternity investigations should continue after April 2023 once the new HSSIB is established. He said the new Special Health Authority will:
- provide independent, standardised, and family-focussed investigations of maternity cases that provide families with answers to their questions about why their loved ones died or were seriously injured;
- help the health system, at all levels, learn from reports aimed at improving clinical and safety practices in trusts, to prevent similar incidents and deaths occurring;
- analyse data from investigations to identify key trends and provide system-wide learning and identify where improvement is, or is not, being made;
- be an expert in standards for maternity investigations and support NHS trusts to improve their own local investigations;
- collaborate with others within the health system to escalate safety concerns and share knowledge and learning.
He said that the government believed that learning from these investigations is the key to achieving the government’s stated ambition to halve (from 2010 figures) the numbers of stillbirths, neonatal and maternal deaths and birth-related brain injuries in babies by 2025.
Why is a new Special Health Authority needed for maternity investigations?
When a baby dies or suffers a brain injury around the time of birth, or a mother dies in childbirth, their families deserve an honest and open explanation of what went wrong. Many families find it difficult to get a full and honest explanation of the events that took place, particularly where mistakes in care may have caused or contributed to the tragic outcome. Over the years, many attempts have been made to encourage high quality investigations and clear communication from healthcare organisations and their staff after maternity mistakes lead to severe harm of the mother or baby.
In 2014, a duty of candour was introduced to force NHS organisations and their staff to tell patients when mistakes have been made in their treatment.
In 2016, a Department of Health consultation, Providing a ‘Safe Space’ in Healthcare Safety Investigations, asked patients for their views on a proposal to provide ‘safe space’ protection which would allow NHS staff to speak freely during investigations into mistakes in patient care. The aim was to overcome the culture of bullying and fear within NHS organisations which prevented staff from speaking openly when things went wrong, so that lessons could be learned from mistakes. The responses to that consultation forced the government to recognise that neither patients nor NHS staff trusted NHS trusts not to abuse the ‘safe space’ system. The use of safe space was put on hold until HSIB, which was set up in 2017, had time to build trust and credibility in the way they handled investigations. In April 2018 HSIB’s remit was extended to include 1,000 maternity investigations per year.
In 2018 the government tried to bring in the Health Service Safety Investigations Bill legislation to create a statutory, independent version of HSIB which would report directly to Parliament. The new Health Service Safety Investigations Body or HSSIB would carry out its investigations under safe space protection. However, that bill did not complete its passage through Parliament after criticisms by the Parliamentary Joint Committee. The Committee accepted that a future HSSIB should conduct national investigations under safe space protection but forced the government to delete its plan for HSSIB to carry out individual maternity incident investigations from the bill, saying that these are the responsibility of NHS Improvement, and should not be carried out under safe space protection by HSSIB.
In July 2021, the Parliamentary Health and Social Care Committee’s inquiry led by Jeremy Hunt said that the NHS was not learning from maternity safety incidents and condemned the rate of improvement in NHS maternity care as too slow. It recommended that HSIB, which by then had carried out more than 1000 maternity investigations, should continue with its maternity investigation programme. A new bill, the Health and Care Bill 2021, is currently making its way through Parliament, and will transform HSIB into the independent, safe-space protected HSSIB.
This week’s announcement by the Health Secretary has finally clarified the government’s intention with regard to maternity investigations, confirming that maternity safety investigations ‘do not follow safe space principles’ and therefore cannot be carried out by HSSIB. The new Special Health Authority will investigate maternity safety incidents, without safe space, but continuing the maternity investigation programme that was developed by HSIB. This is a welcome development, given the immeasurable importance of thorough investigations and open communication to the families of babies and mothers who have been injured by mistakes in maternity care.
Help for parents and families after severe injury from negligent maternity care
Boyes Turner’s clinical negligence team are nationally recognised as leading specialists in high value compensation claims for brain injury, cerebral palsy and other severe injuries caused by negligent maternity care. We have helped countless families obtain answers and apologies, and rebuild their lives after devastating injury and disability. Compensation can help pay for home adaptations, therapies and specialist equipment, and provide financial security for the future with guaranteed provision for the cost of lifelong care.
We recommend that anyone who is contacted by NHS Resolution (the NHS’s defence organisation) or HSIB after their child or their mother have been severely injured by mistakes in maternity or neonatal care, contacts us immediately. We can advise you and guide you through each step of the investigation process, ensuring your questions are answered and your rights to compensation are preserved.
If you are caring for a child with cerebral palsy or neurological brain injury, or have lost a mother or baby as a result of mistakes in maternity care, you can speak to one of our specialist team for advice, free and confidentially, by contacting us here.
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