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MNSI, the leading body for maternity and new born safety investigations related to NHS maternity care in England, published its Annual Report 2023/24 on 7 November 2024. The report provides a comprehensive overview of the strides taken over the past year to improve maternity safety and ensure equitable, personalised care for all mothers and birthing people across England, driven by the ongoing goal of system-wide transformation and learning.

Highlights of 2023/24 progress

The report provides an overview of the work MNSI has carried out over the past 12 months across its key priorities:

1. Reducing inequity: Addressing disparities in maternity care outcomes for black and ethnic minority women and their babies..
2. Improving communication: Carrying out work to improve communication between maternity teams, women/birthing people and families as a key patient safety issue in maternity care. 
3. Thematic learning: Exploring how to enhance the impact of information it holds on thematic learning to inform broader, systemic improvements in maternity safety

The report places special emphasis on the experiences of families involved in MNSI investigations. Families often express a hope that their experiences can prevent future harm to others. This insight drives MNSI’s mission: translating these lessons into actionable, lasting changes within maternity services to ensure safe, personalised care is available to all.

Key themes 

MNSI has identified the following five themes from 1,012 safety recommendations made to trusts during 2023/24, which are similar to those found in previous years: 

• Clinical assessment
• Fetal monitoring
• Escalation
• Clinical oversight
• Risk assessment

Goals for 2024/25

MNSI has outlined its ambitions for 2024/25, which include: 

• Developing the HEART and HEWS tools: MNSI plans to implement the Health Equity Assessment and Resource Toolkit (HEART) and Health Equity Warning Score (HEWS), aimed at improving the recognition and analysis of health inequalities within its maternity investigations. In the long term, these tools will enable MNSI to collect detailed data and identify themes to feedback into the wider system to support targeted interventions and broader health equity initiatives. 
• Advancing thematic learning: MNSI aims to build on its existing work to explore how this information can shape maternity care safety, including identifying opportunities for collaboration which will support a more unified approach to safety improvements. 

Supporting your maternity care goals

At �������ϲ�����, we are committed to supporting NHS Trusts and health care organisations with delivering on their strategy to improve maternity outcomes. Our specialist maternity division can provide advice, support and training to organisations in order to assist with incorporating these recommendations to help reduce the number of incidents and create a safer maternity service. Please do get in touch to discuss how we may be able to help your organisation. 

For more resources and to learn about our specialist team, visit our maternity resources hub.