Learning from Adverse Events in Maternity Services

Delivering safe maternity care is complex and sadly, we know that occasionally adverse outcomes occur that could have been prevented with different care. In most cases there is no single or ‘root’ cause, but rather multiple contributory factors.

The way in which NHS organisations investigate and learn following such events in crucially important. Staff need to be supported and confident that they will be treated fairly, families need to be supported and provided with a truthful explanation of what happened and why. Vitally, the organisation involved needs to ensure that the circumstances are properly reviewed, the factors that contributed to what happened identified and actions put in place to ensure that similar circumstances can’t happen again.

The way the NHS investigates and learns from adverse events has been highlighted as a cause for concern repeatedly in numerous reports over the last two decades1,2,3,4.   In relation to maternity services, the issues were  highlighted in the 2018 Royal College of Obstetricians and Gynaecologists’ Each Baby Counts report5 which reviewed local serious incident investigation reports of term babies who were either stillborn, died shortly after birth or were at risk of brain damage in England in 2016.

The report highlighted the variability in the quality of the local investigations:

  • In almost a quarter of instances, parents were not involved, or even made aware of reviews taking place.
  • 11% of the investigations were of such poor quality that the Each Baby Counts team were unable to make a reliable judgement on the quality of care based on the information available.

Despite best efforts, many organisations are still falling short – the NHSI consultation on developing a new patient safety strategy for the NHS6 (published in December 2018) states:

“… too many patients, families, carers and staff experience closed and defensive cultures when things go wrong in the NHS. Too often they are not supported in the aftermath of harm, including to understand what happened, and too often they have little confidence that the risk of similar harm will be reduced for others.”

We know from feedback we hear from front line maternity professionals that often staff involved in these processes can feel unsupported, inadequately trained or not up-to-date with the plethora of new initiatives.

Baby Lifeline’s new training course

Baby Lifeline has worked with experts from Cranfield University, the Healthcare Safety Investigation Branch (HSIB), NHS Improvement (NHSI) and NHS Resolution (NHSR) to put together a new, 2 day training course specifically designed to provide delegates with crucial training to address these gaps.

Using a combination of formal talks, workshops, and interactive discussions the course covers the following topics:

  • An overview of the national guidance including reporting and notifications requirements.
  • What to expect from external HSIB investigations.
  • Practical training on how to support a ‘just culture’ and provide a culture that supports learning, including tools and key principles and behaviours.
  • Key principles of adverse event investigation, including Human Factors and System thinking in line with the training provided to HSIB maternity investigators.
  • How to sensitively and compassionately engage with families throughout investigation processes.
  • The 72-hour review process, including initial debrief, supporting staff, gathering information and notification/reporting requirements.
  • Hearing directly from an NHS organisation about their improvement journey, how progress was achieved and the barriers and challenges.
  • Practical workshops based on an anonymised real-life scenario so that delegates can practice and use the skills and knowledge gained during the course in practice.

The course will invaluable to anyone working in maternity services, including risk managers, maternity safety champions and those working in safety/quality improvement work. The full course programme is available here.

A course flyer for display in your local organisation can also be downloaded here.

The first course is taking place on 31st October to 1st November in Birmingham. Places are limited to just 50 delegates so please book early to avoid disappointment.




  1. Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. London: Department of Health, 2000
  2. Francis R. The Mid Staffordshire NHS Foundation Trust Public Inquiry. HC 947. London: The Stationery Office, 2013. www.midstaffspublicinquiry.com The previous independent inquiry is available at: www.midstaffspublicinquiry.com/previous-independent-inquiry
  3. Kirkup B. The Report of the Morecambe Bay investigation. London: The Stationery Office, 2015. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf 
  4. Magro M, Five years of cerebral palsy claims; a thematic review of NHS Resolution data, NHS Resolution, London, 2017. Available at: https://resolution.nhs.uk/wp-content/uploads/2017/09/Five-years-of-cerebral-palsy-claims_A-thematic-review-of-NHS-Resolution-data.pdf
  5. RCOG (2018). Each Baby Counts Report 2018. [online] Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/research–audit/each-baby-counts/each-baby-counts-report-2018-11-12.pdf
  6. https://engage.improvement.nhs.uk/policy-strategy-and-delivery-management/patient-safety-strategy/user_uploads/developing-a-patient-safety-strategy-for-the-nhs-14-dec-2018-v2.pdf
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