Who investigates negligent NHS maternity care in England?
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On the 26 January 2022, the Secretary of State for Health and Social Care, Sajid Javid, announced that there are plans to alter the way in which maternity investigations are conducted in England.
Currently, when substandard care in a maternity setting results in a serious injury or death during term labour, the maternity investigations are managed by The Health and Safety Investigations Branch (HSIB). HSIB are a national and independent body whose aim is to make maternity care safer by overseeing investigations into stillbirths, early neonatal deaths, severe brain injury diagnosed in the first seven days of life and maternal deaths.
All NHS Trusts with Maternity Services in England report these kinds of incidents to HSIB, who then aim to investigate the incident in a thorough, independent and impartial way. HSIB investigate in the region of 1000 cases per year and, in each case, attempt to identify common themes and influence systematic change intended to stop the same problems reoccurring. As HSIB are an independent body they are in the unique position to provide reports which do not attribute blame or liability. HSIB state that they ensure the family’s perspective of the events is fully understood so it can be incorporated into the report. They are also in a position to liaise directly with NHS staff.
HSIB was set up following the National Maternity Safety Ambition which launched in November 2015. The Ambition sought to halve the rates of stillbirths, neonatal deaths and brain injuries sustained soon after birth by 2025. In November 2017, the strategy was revised with further measures to improve diligence and the quality of such investigations. It was in April 2018 that HSIB started to oversee the maternity safety investigations and were granted conduct in the Maternity Investigations Programme.
A new maternity care authority has recently been set up
In January 2022, Mr Javid announced that there are plans to establish a new Special Health Authority (SHA) which will conduct the Maternity Investigations Programme, taking the function away from HSIB. The Government has stated it understands the value of independent, standardised and family centred investigations and notes that they should continue beyond 2023. This is something that is in the centre of the media at the moment with the publication of the Ockenden Report. Mr Javid went on to say that 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;
- Provide learning to the health system at local, regional and national level via reports for the purpose of improving clinical and safety practices in Trusts to prevent similar incidents and deaths occurring;
- Analyse the incoming data from investigations to identify key trends and provide system-wide learning in these areas, including identifying where improvements are being made or there is lack of improvement;
- Be a system expert in standards for maternity investigations and support Trusts to improve local investigations; and
- Collaborate with system partners to escalate safety concerns and share intelligence.
The new SHA will start investigations from 2022/2023 and will be fixed for up to five years, to enable maximum learning to be achieved and to provide the NHS with expertise, resources and capacity to take on maternity safety investigations in the future. The Secretary of State for Health and Social Care went on to say that ‘Learning from these investigations is key for meeting the Government’s commitment to make the NHS the best place in the world to give birth through personalised, high-quality support’. The recent Ockenden Report and other maternity investigations over the years have highlighted that this has not been the case historically and, worryingly, issues with maternity care appear to be quite common in many Trusts across the country.
The arrangement to continue independent maternity investigations under the new SHA body is a hopeful development and should ensure that changes and learning on a national basis from investigations takes place in the future. Importantly, the SHA should ensure that every family is involved in the investigations and obtains answers to their questions, which sadly does not seem to have happened consistently to date.
What is the National Investigations Programme?
In addition to the change in maternity investigations, in his announcement Mr Javid confirmed that the National Investigations Programme (which is also currently overseen by HSIB and involves national investigations to improve patient safety issues which are non-maternity related, including concerns with medication and delay in diagnoses) will transfer over to the new ‘Health Services Safety Investigation Branch’ (HSSIB). The reason the two are separate is due to the fact that the maternity investigations do not follow ‘safe space’ principles. The ‘safe space’ principle means that NHS staff can liaise with the investigators without their comments being included within the report. The maternity investigations are not exposed to such arrangements, so any comment from NHS maternity staff can be used in the final report. In addition, the National Investigations are completely separate and do not replace the Trust’s complaint system or serious incident reports. In contrast, the Maternity Programme Investigations will be in place of local and internal hospital inquiries.
Independent Maternity Investigations are a vital component in ensuring that the rates of stillbirths, brain injury and maternal and neonatal deaths are halved by 2025. Every baby who is stillborn, every baby who dies after delivery, every child who is brain injured during delivery and every Mum who loses her life during delivery is a tragedy. Events that take place during labour and how they are managed can have an enormous impact on the patient, their family and their friends. Their lives will never be the same again. The focus has to be on improving maternity safety, being open and transparent with families and learning from previous events, not only locally in the Trust where the event occurred but on a national basis. Only by so doing, will there be any possibility of saving babies’ and mothers’ lives and reducing the number of children born with brain injuries.