Professional Aftercare Toolkit (PACT)

NHS Maternity Investigation Process

Here is a flowchart-style timeline that outlines the investigation process in maternity care within the NHS, from the incident occurrence to the monitoring of implemented actions:

1. Incident Occurs in Maternity Care
2. After ensuring the patient is stable, staff wellbeing is a priority. A ‘hot debrief’ or ‘swarm huddle’ should take place (Swarm huddle).
3. Enter the incident via your Trust reporting system
4. The incident will be reviewed by your governance team. The classification of the incident may be upgraded or downgraded after an initial review of records.
5. If the safety event is likely to have contributed to patient harm, then ‘Duty of Candour’ must be completed. It is important that the voice of the woman and family is considered in any review of care, and they are provided with the opportunity to have their questions answered.
6. An initial patient safety review of care will be completed by the governance team in accordance with the ‘Patient Safety Incident Response Framework’ (PSIRF). The aim is to identify early learning and recommendations on the next steps.

7. If the initial review identifies areas where further exploration is needed to understand how and why the patient safety incident occurred, an appropriate learning response will be selected in line with the organisation’s Patient Safety Incident Response Plan (PSIRP). This may include an After Action Review (AAR), a thematic review or a Patient Safety Incident Investigation (PSII), depending on the circumstances and the potential for further learning and improvement. A suitably skilled and experienced lead reviewer will be appointed to coordinate the learning response.

   Where a baby has died, the Perinatal Mortality Review Tool (PMRT) will be used for eligible perinatal deaths in accordance with national guidance and local policy. This includes late fetal losses from 22 weeks’ gestation, stillbirths and neonatal deaths within 28 days of birth. Where a PMRT review and another learning response are both required, these processes should be coordinated to avoid unnecessary duplication while ensuring that all relevant aspects of care are reviewed and opportunities for learning and improvement are identified.

8. Depending on the nature and circumstances of the incident, external bodies may become involved in investigations or reviews. These may include the Maternity and Newborn Safety Investigations (MNSI) programme, the Nursing and Midwifery Council (NMC) or General Medical Council (GMC), where concerns relate to an individual’s fitness to practise, or HM Coroner. Other organisations, such as the Health Services Safety Investigations Body (HSSIB) or the Medicines and Healthcare products Regulatory Agency (MHRA), may also be involved where relevant. The purpose and scope of each process will depend on the circumstances of the incident.

9. Following all investigations a report will be generated. These will be shared with those involved and later the wider team. Learning may be shared at meetings, huddles, study days to ensure that the team are aware and can learn from the incident and any good practice is highlighted.

10. The governance team will contact the family or the nominated family liaison officer to tell them that the investigation is concluded. They may choose to have a face-to-face meeting; the report sent via post/email or decline any further contact.

This process aims to ensure thoroughness, accountability, and the integration of lessons learned to enhance patient safety in maternity care.