The Health Services Safety Investigations Body has published a new report highlighting that challenges in maternity and neonatal safety stem from systemic national issues, not isolated local failings.
The findings follow extensive scoping work prompted by serious patient safety concerns reported by women, families, and maternity staff.
The report identifies recurring themes from stakeholder interviews and safety reports, including overly complex national systems, inconsistent collaboration, and limited implementation of national recommendations. HSSIB stresses the need to shift focus from individual actions to the broader systems that influence safety outcomes.
Crucially, the report reveals that clinical risks during labour and birth are often unrecognised or poorly managed, and that the system fails to learn effectively from past incidents, litigation, and national inquiries. This lack of learning contributes to repeated harm and undermines public confidence in maternity services.
HSSIB also emphasises the importance of a trauma-informed approach to investigations, recognising that the treatment of women and families after tragic events can compound their suffering. The report notes significant variation in how families feel listened to, reflecting differences in organisational culture.
Staff wellbeing is also a concern, with examples of midwives feeling persecuted and professional confidence damaged due to public scrutiny and recruitment challenges.
In light of the Secretary of State for Health and Social Care’s recent announcement of a national investigation into maternity care, HSSIB has paused its own investigatory work to avoid duplication. However, it has shared its findings with the Department of Health and Social Care and outlined four key areas for potential future investigation:
- National structures overseeing maternity services
- Local governance and its relationship with national bodies
- Standards and approaches to local investigations
- Education, training, and professional standards for maternity clinicians
Director of Investigations at the HSSIB, Philippa Styles, commented:
“This work brings renewed focus to the persistent challenges within maternity safety and reinforces that it is a priority for these challenges to be addressed at a national level.
“The report evidences that serious safety concerns continue to exist across maternity services, despite past events. We need to ensure safety concerns are effectively and proactively understood and managed to ensure significant improvements are delivered.
“There needs to be more positive support for staff working in maternity and neonatal services. A culture focused on blame is impacting their wellbeing and their ability to work effectively but will also stifle progress because they feel fearful to speak up about their concerns. Enabling staff to speak freely, without repercussions, is vital to supporting a positive and collaborative approach to improving maternity safety.
“We strongly believe the valuable insights from our work can inform the national system-wide investigation and support the delivery of safer care for women and their families. We hope the investigation chaired by Baroness Amos will take this into consideration.”
This report reinforces the urgent need for system-wide reform to improve safety, restore trust, and ensure that women, babies, and staff are protected and supported.
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