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Healthcare Safety Investigation Branch makes over 1,500 recommendations to NHS trusts after hundreds of serious maternity incidents

Posted: 27/08/2021

The Government’s healthcare safety adviser, the Healthcare Safety Investigation Branch (HSIB), has made a wide range of recommendations over the last year following investigations into hundreds of incidents that have uncovered repeated errors involving NHS trusts. HSIB, which is part of NHS England, has focused on NHS maternity units following scandals relating to poor-quality care, such as the one at Shrewsbury and Telford Hospital concerning a series of particularly serious failures.

The quality of care in maternity units has been the subject of significant scrutiny in recent years, including by the Health and Social Care Committee, which made recommendations that included ensuring women have a personalised care and support plan. These recommendations are examined in more detail in the panel below.

Donna Ockenden’s independent review focused on midwifery services at Shrewsbury and Telford but also nationwide maternity units. The full report is unpublished, but an interim report was published in December 2020, in recognition of an urgent need for change. Conclusions included a need to coordinate neighbouring trusts working together so that local investigations have external oversight, and ensuring women and families are listened to by those responsible for their care.

An update in May 2021 stated that some advances were being made under the direction of NHS Improvement, and noted that as a result of the interim report, £95 million had been invested in maternity services in England with the aim of increasing the number of midwives and obstetricians. In addition to creating more jobs, this investment should ensure that existing staff are better supported and improve the culture by reducing workplace stresses among obstetric and midwifery staff.

The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) have announced that where doctors’ or midwives’ actions or attitudes pose a continuing risk to patients, they will investigate and take any regulatory action necessary to protect the public.

It may be questioned whether these actions are enough. The Health and Social Care Committee recommended increasing the budget for maternity services by £200 – 350 million per annum, some of which should be ring-fenced for training. The GMC has stated that its own regulatory powers are insufficient. Charles Massey, the GMC chief executive, wrote in June 2021:

"The world in which doctors practise today is fundamentally different but the legal framework governing how they’re regulated has remained largely unchanged. Until now, regulators have tried to work around this, pushing at the boundaries of legislation to make our interventions more responsive. But we’ve reached the limits of what we alone can do."[1]

The Care Quality Commission (CQC), an executive body of the Department of Health, has also taken a role in overseeing the quality of care, and has downgraded multiple hospitals in recent months due to concerns about women’s safety, highlighting poor communication between staff.

HSIB’s role is to investigate serious incidents referred to it by NHS trusts within hours. It is responsible for the investigation of maternity cases involving stillbirth, neonatal death, or severe brain injury. Some 760 referrals were made to HSIB between April 2020 and March 2021, involving 125 NHS trusts. Half of these referrals related to babies who had suffered brain damage, 147 involved stillbirths, and 66 concerned the death of the mother during childbirth.[2]

The recommendations published by HSIB as a result of these investigations include an early warning system to spot women who are starting to experience problems, which should be available in any setting including A&E departments; better quality clinical records that are easier to access; and a named consultant being responsible for oversight of the care of mothers with complex needs. Overall, the HSIB has made more than 1,500 safety recommendations to NHS trusts.[3]

Although the serious incidents are shocking and make headlines, it is not just these incidents that need addressing. It is hoped that a culture that offers women choice can be encouraged, for example by ensuring they are fully informed of the safest options for them, so they can take decisions on their care themselves with the support and advice of their doctors. Instances in which this objective is not being met include the underuse of Caesarean sections in a small minority of NHS trusts, where natural births are preferred in order to improve statistics and ratios, and women not being informed of the danger of Group B Strep (GBS) and the possibility of being tested for GBS cheaply (further detail on GBS screening is also provided in the panel below).


[1] General Medical Council, Monday 21 June 2021, GMC publishes response to the Department of Health and Social Care’s consultation on regulatory reform, available at:

[2] Independent, Monday 16 August 2021, Hundreds of maternity incidents in one year prompt 1,500 safety instructions to hospitals, available at:

[3] Ibid.


This article has been co-written with Dominik Young, a trainee solicitor in the clinical negligence team. 

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