NHS Maternity Investigation Process Timeline

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:

Incident Occurs in Maternity Care
After ensuring the patient/woman is stable staff wellbeing is a priority – you may choose to undertake a swarm huddle (guidance on how to perform a swarm huddle can be found here – B1465-Swarm-huddle-v1-FINAL.pdf)
Enter the incident via your Trust reporting system
Incident will be reviewed by your Governance team. The classification of the incident may be upgraded and/or downgraded after an initial discussion/review of records.
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/family is considered in any review of care, and they are provided with the opportunity to have their questions answered.
An initial patient safety review of care will be completed to identify early learning and recommendations on the next steps.
If the incident meets the criteria for external bodies such as the Maternity and Newborn Safety Investigation (MNSI) team and/or MBRRACE to enable a PMRT review of the care to be completed the maternity governance team will undertake this. For MNSI cases it is unlikely your Trust will undertake another formal review of care.
If the next steps of the initial review have identified areas which require further explorations and understanding of why the safety event occurred an After-Action Review (AAR), a Thematic Review or a PSII Review will be commissioned. Additionally, an appropriate lead reviewer will be appointed.
It is important that a Terms of Reference for the investigation/review are developed because they will determine how effective the investigation is and satisfaction with its output.
AAR – These are usually conducted in groups and seek to understand;

What was meant to happen

What actually happened

Why the event happened

What the learning is.

A Thematic Review – it may be decided that the best way to understand why a safety event is recurring is via a thematic review rather than conduct another written review of another similar incident in isolation. For example, there may be a number of postpartum haemorrhages occurring in theatre and using the SEIPS framework to undertake a thematic review may provide further insight and broaden the learning.
A PSII Review may be undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning.
Draft review – It is good practice to ask a small team to review your investigation and make comments. They may have a different view, and this will omit bias in the analysis and recommendations.
Action Plan: Ensure that your actions are SMART, Specific, Measurable, Achievable, Relevant and Time bound.
Final Report: Once the final report is agreed and shared at the appropriate governance/Trust meeting it can be shared with the wider team. It is good practice to update those involved prior to this. This will ensure they are offered any support they require either psychologically or clinically.
Wider Learning – The report may be shared at meetings, huddles, study days etc to ensure that the team are aware and can learn from the incident and any good practice is highlighted.
Family feedback – The governance team will contact the family or the nominated family liaison officer to tell them that the report is concluded. They may choose to have a face-to-face meeting; the report sent via post/email or decline any further contact.
Monitoring: The effectiveness of actions is continuously reviewed and adjusted as necessary to ensure that the implementation of any new ways of working is effective and so that assurance can be provided that the learning is embedded.

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