Summary of Themes arising from the Healthcare Safety Investigation Branch Maternity Programme

What We Can Learn from HSIB’s Thematic Review to Improve Safety

By Sara Ledger, Head of Research & Development, Baby Lifeline Training


The Healthcare Safety Investigation Branch (HSIB) has been responsible for conducting external investigations for almost two years in NHS maternity services across England. The investigations are based on babies who fulfil the Each Baby Counts criteria and aims to make safety recommendations to local and national organisations for system-level improvements in maternity.

The safety recommendations are based on what comes out of investigations, audits and safety studies, with the aim of preventing avoidable harm in the future where possible. The recommendations are not only relevant to local trusts, but also maternity networks and national bodies. Crucially, HSIB works with families to share and gain information as the investigations are ongoing.

The report, published this week, identifies prominent themes in HSIB’s safety recommendations:

  1. Early recognition of risk
  2. Safety of intrapartum care
  3. Escalation
  4. Handovers
  5. Larger babies
  6. Neonatal collapse alongside skin-to-skin contact
  7. Group B streptococcus
  8. Cultural considerations
Early recognition of risk

Risks related to:

  • Multiple episodes of reduced fetal movements
  • Changes in maternal health: medical or mental
  • Lack of follow-up relating to referrals to specialist services
  • Fundal height measurements and/or ultrasound scans not being plotted on a chart
  • Timely follow-up of test results – extending to not being recorded and considered by the maternity triage service or delivery suite staff. This can mean that women remain at “low risk” where is sometimes inappropriate.

This is where we defer back to one of our expert’s phrases: “low risk does not mean no risk”. Ensuring that all appropriate measures are taken to appropriately assess all women in her antenatal care through to labour is vital to ensure appropriate and timely escalation and management.

Safety of intrapartum care

There was variance in the quality and comprehensiveness of advice given to mothers who had contacted their maternity unit and were experiencing signs or indications of early labour:

  • Assumptions that the mother was fully aware of her care pathway and so no risk factor assessment was carried out.
  • High risk vs low risk care:

High risk mothers generally tended to receive appropriate care where there was good anticipation of changes in risk factors. In those assessed as low risk, however, there were delays in considering alternative care pathways when there were changes in the condition of the baby or mother.

  • Documentation at triage was not adequate, which meant that where multiple calls were made by the mother, decision making was hindered.
  • Advising the mother to stay at home without the full assessment of the clinical picture. In some cases, this inhibited safe care, especially for the following groups:
    • Those carrying Group B strep
    • SGA babies
    • Those with a history of lack of fetal movements

HSIB note that it is important to consider that for more vulnerable babies the stresses of labour begin with contractions, and not when the cervix has reached certain dilatation.

  • “The 4cm rule”: HSIB found examples of mothers and babies that would have benefited from an earlier admission to Labour Ward, before they were 4cms dilated. It is again important to consider the full clinical picture beyond dilatation.
  • Sending mothers home: It is important to consider that a mother presenting at hospital may already think they are in established labour and not know when to return to the hospital. HSIB found that mothers were returning to hospital in the advanced stages labour and one-to-one care during labour was missed.

There will be a further comprehensive review by HSIB in systemic factors associated with delays to intrapartum intervention once fetal compromise is suspected – expected in 2021.


“Failure to escalate” is often noted as a reason for inadequate care leading to avoidable harm in maternity. HSIB found the following themes:

  • Stepwise escalation processes which inhibit a medical professional from seeking support directly.
  • Lack of clarity and support from senior members of the team.
  • Not knowing what to do next if escalation criteria have been met but no clear guidance given.

HSIB states that situations in which these things happen often colours the future management by staff members, and so can impact on care for many mothers and babies; therefore, it is important that we get this right.

  • “Fresh eyes” can sometimes lead to clinical aspects being viewed in isolation and can also sometimes lead to confirmation bias; therefore, not for the intended purpose of providing staff with support in decision making.
  • Problems with escalation were noted in particular with fetal monitoring.

Quality of handovers in care was another major theme in the maternity investigations, with the following main areas of concern:

  • Information lost during handover, even when Trusts had good communication systems in place – ineffective use led to poor information transfer.
  • Reluctance to interrupt handover can lead to a delay in support and intervention.
Larger Babies
  • HSIB reported that discussions about potential risks for larger babies with mothers were not often had and did not facilitate informed choices around mode of delivery.
  • Multi-professional training covering emergency scenarios sometimes did not always allow staff to anticipate or have an adequate understanding of them.
  • It was not always recognised or communicated in a timely manner when the neonatal team may need to be present for the birth of a larger baby.
Neonatal collapse alongside skin-to-skin

It was found that attention could be focused towards the mother and carrying out documentation and not enough on observing the baby, which can lead to avoidable harm.

  • Mothers are sometimes unable to check the baby’s position or generally observe the baby due to exhaustion.
  • Subtle changes in skin colour can go unnoticed due to the baby being covered during skin-to-skin to maintain temperature.
  • Investigations found that some baby’s airways became obstructed due to suboptimal positioning after birth.

Following on from these observations HSIB has worked with Unicef on their Baby Friendly Initiative to ensure these are taken into account.

Group B Strep

Investigations found suboptimal care relating to Group B Strep:

  • Mothers were not always provided with all information recommended by the RCOG in relation to Group B Strep, which could limit decisions relating to antibiotic use during labour and also timely attendance to hospital.
  • Documentation during triage, and mothers being asked to stay at home.
  • Positive tests for Group B Strep were not communicated to the mother or noted clearly; therefore, recommended care was not given.
  • Escalation of care for babies showing signs of Group B Strep after birth were missed.
Cultural considerations

“The impact of culture, ethnicity and language of parents needs to be discussed and considered during the antenatal risk assessment process, during initial assessment and during follow up.”

Investigations found:

Misunderstandings and miscommunications between staff and parents from BAME communities, which can lead to inappropriate care and decisions made by the mother.

  • Language barriers were found to be the cause of miscommunication with non-English speaking parents. Sometimes translation services were not used by staff, were sometimes not available, and sometimes not used at a relevant time.
  • Sometimes members of staff or family members were used as translators, which could have led to misunderstandings.
  • If the mother could speak good English then often there is an assumption that she can understand all aspects of her care.

Different cultural expectations around what the mother is expected to do and the options they have available to them. For example:

  • Accessing support (e.g. pain relief)
  • Inability to challenge the care being provided or ask questions.


Please read HSIB’s full report for vignettes and further information.

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