The MNSI annual report 2024/5 – what you need to know

The MNSI (Maternity & Newborn Safety Investigations) body has published its annual report for 2024/2025; this provides an overview of their programme during this period and outlines its plans for the following year. MNSI seek to provide healthcare organisations, policymakers and the public with insights into outcomes of their investigations.

Since their last report, MNSI have now started including safety prompts as well as safety recommendations. Safety prompts are used where there is no sufficient evidence to support a safety recommendation or the issue fell outside the direct scope of the investigation.

Their findings have been sourced from 613 investigations from which 1,122 recommendations were made and 840 safety prompts.

Through the use of artificial intelligence, MNSI have suggested that the most recurring themes stemming from their investigations were:

1. clinical assessments and risk evaluations;
2. labour and birth processes, especially around fetal monitoring using cardiotocographs (CTGs);
3. the importance of escalation protocols and information sharing;
4. ensuring systematic processes and support for clinicians;
5. emphasis on triage and holistic care.

Furthermore, MNSI have adopted a number of changes in the structure of their reports which include:

• a clearer, more accessible reporting style so that families and Trusts can better understand the findings and learning;
• using health-equity tools such as HEART and HEWS to ensure that health equity considerations are integrated into the investigation;
• piloting COMPASS (Culture of Organisations and its Impact on PAtientS’ Safety) to help identify and analyse cultural factors within organisations that may affect patient safety.

Moving forward, MNSI plan to build on the highlighted safety themes by developing a more detailed coding system so that they can more quickly categorise investigation findings and further explore AI analysis so that they can identify patterns and recurring issues. It is their hope that through this, they will be able to assist Trusts with more proactive safety improvements.

Those of us who work with families are hopeful that the adopted changes in MNSI’s report will lead to more robust and transparent investigations to adverse outcomes in NHS Maternity case and that this will lead to meaningful changes implemented across maternity services.