MNSI's 2023/24 Annual Report - 945 referrals for stillborn, neonatal and maternal deaths and brain-injured babies

The Maternity and Newborn Safety Investigation programme (MNSI) has published its 2023/24 Annual Report. The report is MNSI’s first annual review since the maternity safety watchdog began operating independently from the former HSIB in October 2023, but the annual and cumulative statistics and recurring themes it presents continue to cause concern.   

From April 2023 to March 2024, MNSI received referrals from NHS maternity services of 945 incidents involving the birth-related, hypoxic brain injury or death of a new baby or the death of pregnant, birthing or post-natal mother. Each of these deaths or life-changing injuries will have caused devastating loss, with lasting consequences for a child, their parents and wider family. For many, these tragic outcomes will have been avoidable.

What is MNSI?

The Maternity and Newborn Safety Investigation (MNSI) programme investigates safety incidents related to NHS maternity care in England that have led to the pregnancy-related death of a mother (maternal death), or the death of a full-term baby during labour and delivery (intrapartum stillbirth) or within the first week of life (early neonatal death).

MNSI also investigates birth injuries to newborn, full-term babies who are diagnosed with severe brain injury, involving either a grade III hypoxic ischaemic encephalopathy (HIE), treatment with cooling, or decreased central tone (floppiness), loss of consciousness and seizures (fits or convulsions). Since the pandemic, HSIB, and later MNSI, have not investigated cases where the baby’s MRI scan or neurological examinations reveal no obvious evidence of ongoing brain injury, such as after cooling, unless the family or the NHS trust request an investigation. 

In most cases, maternity safety incidents which meet these criteria are referred to MNSI by the NHS trust that was responsible for the mother’s maternity care. If MNSI accepts the referral, and if the family consents to the investigation and allows MNSI access to their medical records, MNSI’s investigation then replaces any investigation that would be carried out by the NHS trust or maternity hospital. MNSI’s investigations don’t attribute blame or liability to individual healthcare professionals, but explore the factors within the systems and processes which contributed to the harm. Based on their findings, MNSI make safety recommendations which they hope will improve healthcare systems and processes, reduce risk and improve safety, but the responsibility for implementing MNSI’s safety recommendations remains with the NHS trust.  

After their investigation, MNSI shares the investigation report with the injured child or mother’s family and with the NHS trust, as well as with the NHS’s defence organisation, NHS Resolution. MNSI also identifies recurring themes that arise from their maternity safety investigations, so that they can make safety recommendations for learning within the wider maternity healthcare system.

Birth injury statistics from MNSI’s 2023/24 Annual Report

Between April 2023 and March 2024, MNSI received 945 referrals from NHS trusts relating to babies who had suffered intrapartum stillbirth, neonatal death or birth-related severe brain injury, or relating to maternal deaths. 795 of those met MNSI’s investigation criteria and 591 maternity safety incidents were investigated. Where eligible referrals were not investigated, this was because they did not meet MNSI’s criteria, or because there was no obvious evidence of ongoing severe brain injury, or because the family did not agree to share their medical records, which is now essential for an MNSI investigation to proceed.

Of the referred cases, 319 related to severe brain injury to a child. 140 were stillbirths, 80 were early neonatal deaths and 52 were maternal deaths. MNSI completed 554 reports within the 2023/2024 year.

Since the maternity safety investigations programme was launched in April 2018, there have been a total of 6,018 referrals, of which 3,856 proceeded to investigation, with 3,505 investigations completed by 31^st March 2024. MNSI reports that 86% of families engage with their investigations.

Recurring safety themes in maternity care

MNSI identified clinical assessment, fetal monitoring, escalation, clinical oversight and risk assessment as the top five common themes emerging from their safety recommendations to NHS trusts during maternity investigations in 2023/24. Many of these themes are all too familiar, and have been highlighted repeatedly as maternity safety concerns over the last few years in reports by organisations concerned with maternity safety, such as MBRRACE-UK, RCOG’s Each Baby Counts programme, NHS Resolution and HSIB.  Fetal monitoring was also one of the maternity safety themes recently highlighted by MNSI in its national learning report, ‘Factors Affecting the Delivery of Safe Care in Midwifery Units’.

MNSI’s report also highlights its ongoing activity in other important risk areas for maternity safety, such as communication, inclusivity and health inequalities, spurred on by statistics by MBRRACE-UK and other maternity safety reports showing alarming disparities in the mortality rate for Black and ethnic minority women and their babies compared with those of white ethnicity.

Recognising the need for system-wide change

MNSI’s report highlights the hope expressed by countless injured families that the learning from their experience will ensure that no other family goes through what they have experienced, but the report acknowledges that currently this remains an ambition within maternity care in England which is yet to be achieved. The report calls for prioritised and sustained action to ensure that everyone receives safe, personalised maternity care, and refers to the system-wide change which is needed to turn this ambition into reality.

MNSI say that their highest priority going forward is to develop a more detailed understanding of the factors that support safe and equitable maternity care, and ask (rhetorically), ‘Why do women, birthing people and babies not receive optimal individualised care?’ Sadly, in her foreword to MNSI’s report on yet another year of heartbreaking statistics, Sandy Lewis, Director Maternity and Newborn Safety Investigations concludes that, so far, they ‘have only touched the surface of the reasons behind these factors’.

If your child has cerebral palsy or neurological disability as a result of medical negligence or you have been contacted by HSSIB/MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.