Recommendation 11

We believe that HSIB’s ability to take a broad and independent view of the services and factors contributing to maternity incidents is a valuable step in the right direction to learning from maternity incidents. It is essential that an independent, standardised method of investigating the most serious incidents is maintained. However, there is still work to be done to improve the timeliness of investigations and the relationship between HSIB and trusts to ensure there is local ownership of recommendations made and investigations maximise learning at the local level. That relationship should not be confined to senior management; all members of the team, and in particular junior members of the clinical team, should be able to engage with an investigation in a manner which increases learning and the implementation of recommendations. Trusts should also improve local and regional sharing of key learnings particularly through Local Maternity Systems (LMS).