The HSIB approach to maternity investigations

Source: NHE Jan/Feb 18

Jane Rintoul, director of strategy and policy and programme director for maternity investigations at the Healthcare Safety Investigation Branch (HSIB), explains more about the organisation’s independent approach to improving maternity safety.

In November 2017, the secretary of state for health announced a new maternity safety strategy detailing plans for the HSIB to undertake around 1,000 independent safety investigations into avoidable baby deaths and incidents of harm.

These investigations are expected to start in April, and will focus on cases that meet the Each Baby Counts (EBC) criteria for intrapartum stillbirth, neonatal deaths and severe brain injuries, as well as all maternal deaths. The EBC is a dedicated programme, established by the Royal College of Obstetricians and Gynaecologists, to gather intelligence and information from local serious incident investigations and build a picture of national issues.

Our aim is to bring a standardised approach to maternity investigations without attributing blame or liability and to ensure that families are involved throughout the investigation. The HSIB maternity implementation team are working through the finer details around approach and methodology but each investigation will:

  • Identify the factors that may have contributed towards death or harm;
  • Use evidence-based accounts to establish what happened and why;
  • Produce concise reports in the shortest time possible.

Focusing on individual cases

The reports for the maternity investigations differ slightly from those produced for national investigations in that they’ll focus in on individual cases. However, wider dissemination of learning is crucial in preventing future tragedies and we can use our position as an independent national investigator to aggregate all the findings from the reports and generate wider recommendations.

Another difference with our maternity investigations is that they will replace the local investigation if it meets the EBC criteria or maternal deaths that meet certain criteria. We’ll work alongside staff in the affected organisation, as their local and clinical knowledge is key to building our understanding as well as offering support and guidance on investigative techniques and practices.

We don’t underestimate how big an undertaking this is for the HSIB, but we recognise the importance of providing consistent, high-quality investigations that provide a national view of maternity safety.

As our chief investigator Keith Conradi said, “each one of these cases represents a tragedy for the family involved and each one deserves the professional safety investigation that HSIB can deliver.”

We look forward to producing the first reports and we trust that the maternity investigations can act as a vanguard, providing a model for improvements in other clinical areas.


HSIB continues to look for skilled clinicians and investigators from a range of backgrounds to make a national impact on reducing maternity-related deaths and injuries. It is aiming to recruit around 100 investigators in total, with teams based across England.


To register for job alerts and for more information on current opportunities, please visit:


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