Annual publication of MNSI safety recommendations 2025 to 2026
- Recommendations
- —
MNSI's description: Our approach to sharing safety learning
MNSI Maternity Investigations
Published learning from the Maternity and Newborn Safety Investigations programme, which investigates around 600 maternity cases a year across all 120 trusts providing maternity care in England. Individual investigation reports go to the family and trust only; the public record is the publications list at mnsi.org.uk, held here.
43 publications618 investigations completed (2025/26)1,300+ safety recommendations made (2025/26)
Coverage: Official source scope
Newest content date: 14 Oct 2026. This describes the content held here, not the date this page was opened.
How this source is collected and updated
- Collection method
- Curated
- Observed update
- Updated occasionally
- Last record written
- 24 Oct 2026
Records written on 1 of the last 90 days; last write 24 Oct 2026.
Publisher's stated schedule: Periodic. That is the publisher's own description, not a measurement of this copy.
Reports and publications
MNSI Annual Report 2025/26 published
- Recommendations
- —
MNSI's description: This years annual report highlights work carried out between April 2025 and March 2026 to improve maternity and newborn safety in England.
Safety Spotlight: Caring for pregnant women admitted to non-maternity hospital wards
- Recommendations
- —
MNSI's description: Safety prompts to consider when caring for pregnant women admitted to non-maternity hospital wards
Learning from investigations where intrapartum care has been given at home
- Recommendations
- —
MNSI's description: A new national learning report has been published setting out a number of areas in which care could be improved for women receiving intrapartum care at home.
Briefing paper: Remote hospital working
- Recommendations
- —
MNSI's description: A thematic review was conducted to explore the impact that remote hospital working can have on the provision of maternity and neonatal services.
Safety spotlight: Calling for help in obstetric cardiac arrests
- Recommendations
- —
MNSI's description: This safety spotlight focuses on delays in calling the emergency team during obstetric cardiac arrests.
Briefing paper: Newborn cooling practices
- Recommendations
- —
MNSI's description: MNSI has reviewed 20 investigations into the cooling of term babies across England. The findings show that national guidance on continuous temperature monitoring during cooling was not followed in half of cases.
Safety spotlight: Nitrous oxide
- Recommendations
- —
MNSI's description: This safety spotlight shares what we found regarding nitrous oxide decommissioning and offers prompts to help providers keep staff informed and equipment checks consistent.
Safety spotlight: HbA1c testing in women with sickle cell trait
- Recommendations
- —
MNSI's description: Laboratory tests for glycosylated haemoglobin (HbA1c) can underestimate past glycaemia in people with haemoglobin variants, such as those with sickle cell trait. This is because there is an increased red cell turnover in those with...
Safety Spotlight: Investigations into equipment and technology used for continuous fetal heart rate monitoring
- Recommendations
- —
MNSI's description: A baby's heart rate was being monitored with a CTG abdominal transducer. The mother's heart rate was also being monitored using a finger probe pulse oximeter, attached to the CTG machine. The mother and baby’s heart rates were displayed...
Launch of new MNSI thematic review: Homebirth
- Recommendations
- —
MNSI's description: In response to learning identified from MNSI (formally Healthcare Safety Investigation Branch (HSIB)) maternity investigations, MNSI wants to further understand how systems and pathways affect the safe delivery of intrapartum care at home....
Maternal Care Bundle safety spotlights
- Recommendations
- —
MNSI's description: We welcome the publication of the Maternal Care Bundle by NHS England and are delighted to have been a key contributor in its development. A series of safety spotlights follow.
Safety spotlight: Late diagnosis of breech presentation
- Recommendations
- —
MNSI's description: MNSI has completed a number of investigations where there has been a late diagnosis, in established labour, of a baby being in breech presentation during an induction of labour.
Safety spotlight: Mothers with a learning disability
- Recommendations
- —
MNSI's description: Maternity care should be responsive to every woman’s needs.
Annual publication of MNSI safety recommendations 2024-25
- Recommendations
- —
MNSI's description: MNSI publishes the safety recommendations from MNSI investigations completed in 2024/25.
MNSI Annual Report 2024/25 published
- Recommendations
- 1,122
MNSI's description: MNSI’s Annual Report 2024/25, highlights work carried out between April 2024 and March 2025 to improve maternity and newborn safety in England.
Briefing paper: Learning from resuscitative hysterotomy after out-of-hospital cardiac arrest
- Recommendations
- —
MNSI's description: The Maternity and Newborn Safety Investigations (MNSI) programme has published a new briefing paper sharing learning from investigations of resuscitative hysterotomy (RH) following out-of-hospital cardiac arrest in pregnancy. The paper is...
Safety Spotlight: Therapeutic cooling practices
- Recommendations
- —
MNSI's description: Our investigations into therapeutic cooling practices have identified areas of learning in relation to passive cooling.
Safety Spotlight: Exchange blood transfusion
- Recommendations
- —
MNSI's description: A baby received an exchange blood transfusion. This is a specialist and complex procedure with associated risks (and is now infrequently performed in most neonatal units).
Safety spotlight: Reviewing and actioning laboratory test results
- Recommendations
- —
MNSI's description: MNSI has undertaken investigations where laboratory test results have not been reviewed and actioned.
Safety Spotlight: Prescribing and dispensing of low molecular weight heparin
- Recommendations
- —
MNSI's description: Things MNSI recommend considering when prescribing low molecular weight heparin to avoid incorrect doses being dispensed.
Safety Spotlight: Incomplete observations generating incorrect EWS
- Recommendations
- —
MNSI's description: MNSI has investigated a number of patient safety events where an incomplete set of observations generated an early warning score (EWS) via an electronic patient record (EPR) system.
Safety Spotlight: Changes to the MNSI investigation report template
- Recommendations
- —
MNSI's description: On 1st April 2024, six months after the transition to being hosted by the CQC, MNSI changed their investigation reports and process.
Safety Spotlight: Maternal Deaths in the first trimester from Venous Thromboembolism (VTE)
- Recommendations
- —
MNSI's description: MNSI has undertaken investigations of maternal deaths in the first trimester from venous thromboembolism (VTE)
Safety Spotlight: Patient Ethnicity Data Collection
- Recommendations
- —
MNSI's description: MNSI has found that inaccurate or missing recordings of a woman’s ethnicity have impacted her subsequent pathway of care.
Briefing paper: Birthing outside of guidance
- Recommendations
- —
MNSI's description: We have identified ‘birthing outside of guidance’ as a national learning theme through our maternity investigations. Between September 2018 and December 2023 we have made recommendations relating to birthing outside of guidance 33 times.
Safety Spotlight: Delayed escalation in abnormal CTGs
- Recommendations
- —
MNSI's description: MNSI has completed a number of investigations in which time limits, as described in national guidance, have delayed categorisation of CTG recordings, resulting in delays in escalation.
Annual publication of maternity safety investigation recommendations 2023 to 2024
- Recommendations
- —
MNSI's description: MNSI publishes the safety recommendations from MNSI investigations completed in 2023/24.
MNSI Annual Report 2023-24 Published
- Recommendations
- —
MNSI's description: MNSI launches it's annual report
Factors affecting the delivery of safe care in midwifery units
- Recommendations
- —
MNSI's description: This report is intended for healthcare organisations, policymakers and the public. It is based on a thematic analysis (a process that looks for common themes) of 92 maternity investigation reports, where the safety incident under...
Safety Spotlight: Deaths from Anaphylaxis
- Recommendations
- —
MNSI's description: MNSI is aware of maternal deaths from anaphylaxis.
Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection
- Recommendations
- —
MNSI's description: This document was published when our programme was part of the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy .
Maternity investigation programme year in review 2022/23
- Recommendations
- —
MNSI's description: Summary of highlights, themes and future work.
Maternity investigations glossary of terms
- Recommendations
- —
MNSI's description: An explanation of the clinical terms used in our reports, in plain language.
Assessment of risk during the maternity pathway
- Recommendations
- —
MNSI's description: This document was published when our programme was part of the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy .
Maternity investigation programme year in review 2021/22
- Recommendations
- —
MNSI's description: Summary of highlights, themes and future work.
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020
- Recommendations
- —
MNSI's description: This document was published when our programme was part of the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy .
Maternity investigation programme year in review 2020/21
- Recommendations
- —
MNSI's description: Summary of highlights, themes and future work.
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
- Recommendations
- —
MNSI's description: This document was published when our programme was part of the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy .
Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia
- Recommendations
- —
MNSI's description: This document was published when our programme was part of the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy .
Neonatal collapse alongside skin-to-skin contact
- Recommendations
- —
MNSI's description: This document was published when our programme was part of the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy .
East Kent Hospitals University NHS Foundation Trust: HSIB summary report
- Recommendations
- —
MNSI's description: A summary of the investigations undertaken with East Kent Hospitals University NHS Foundation Trust.
Summary of themes arising from the Healthcare Safety Investigation Branch maternity programme
- Recommendations
- —
MNSI's description: National learning report covering the period between April 2018 and December 2019.