The Maternity and Newborn Safety Investigations (MNSI) programme: what you need to know

When investigating patient safety incidents, it is vital that this is done in an open and honest manner, without apportioning blame. Independent investigations play an important role in understanding what happened, identifying opportunities for learning, and improving patient safety. So, what should you do if you become involved in a Maternity and Newborn Safety Investigations (MNSI) investigation.

Fin Wright, Case Manager at Medical Protection, explains.

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In medicine, it is vital that adverse incidents and near misses are reported and investigated in an open and honest manner, to enable lessons to be learned and any necessary changes to be implemented. Doctors have a professional duty to be open and honest with patients following an adverse incident, as outlined by the GMC and NMC in their guidance Openness and honesty when things go wrong: The professional duty of candour. In addition to this there is also a statutory duty to take certain steps when a “notifiable incident” has occurred.

In some cases, independent bodies may be instructed to investigate serious patient safety incidents. This has become an established feature of maternity services in NHS hospitals, particularly following maternal deaths, stillbirths, neonatal deaths and cases involving potential severe brain injury to a baby.

Between 2018 and 2023, these investigations were undertaken by the Healthcare Safety Investigation Branch (HSIB) maternity programme. In October 2023, the programme transferred to the Maternity and Newborn Safety Investigations (MNSI) programme, which is now hosted by the Care Quality Commission (CQC). The transition ensured the continuation of independent, family-focused maternity investigations, whilst the wider national safety investigation function moved to the Health Services Safety Investigations Body (HSSIB).

MNSI conducts independent investigations into qualifying maternity and newborn incidents across NHS-funded care in England. Its aim is to identify the factors that contributed to an adverse outcome, promote learning, and improve the safety and quality of maternity and neonatal care. As part of this work, MNSI engages with families, healthcare professionals and healthcare organisations to support learning and reduce the risk of similar incidents occurring in the future.

If you are meeting with the MNSI

Medical Protection have taken a number of calls from members concerned about having been approached by the MNSI to assist with their investigations. The MNSI requests practitioners to attend an ‘interview’ to discuss a particular case, as opposed to requesting a statement. Member calls to Medical Protection have also expressed concern that these meetings will be recorded.

It is commonplace for the MNSI to ask for consent to record these meetings and, although this may at first appear daunting, a recording will ensure that there is an accurate record of any information given, and it would be more accurate than a minute taker. The MNSI are amenable to interviewees taking along a work colleague for support if required; it is advisable to let the MNSI know who that will be prior to the meeting. The MNSI will conclude their investigation with a report, and a draft version will be sent to those involved to check for factual accuracy before it is finalised. There is some helpful information on their website regarding the meetings which you may wish to consider.

The nature of the investigative process means that preparation is everything, and there are a number of other important points to bear in mind that will help during the meeting:

It is important to keep in mind that this investigation’s aim is not to apportion blame, and instead it is to understand what happened and make safety recommendations to prevent a reoccurrence of similar events in the future.

Writing a report

The MNSI usually holds an interview instead of requesting a report, but you may wish to prepare for the meeting by drafting a report regarding your involvement, which you can refer to during the interview and even provide to the MNSI. The GMC states the following regarding report writing in paragraph 89 of Good Medical Practice:

‘You must make sure any information you communicate as a medical professional is accurate, not false or misleading. This means:

Medical Protection also provides the following advice:

More information on report writing can be found in our guide to writing medical reports. If you have any other queries or concerns about meeting with the MNSI or would like Medical Protection to review your report prior to the interview, contact the Medical Protection advice line on 0800 561 9090.