The Healthcare Safety Investigation Branch (HSIB) was established to investigate safety incidents. The purpose is to learn lessons, to change and improve patient safety, and to share recommendations to prevent similar incidents from happening again. It does not apportion blame.

HSIB investigations are independent in that they do not investigate on behalf of families, staff, organisations or regulators.

What is a HSIB maternity investigation?

Part of the current HSIB remit is to investigate the safety of maternity services in the NHS as part of a national action plan to improve safety and reduce the number of stillbirths, neonatal and maternal deaths, and brain injuries.

HSIB investigate incidents that meet the Each Baby Counts criteria or their defined criteria for maternal deaths.

Each Baby Counts is the Royal College of Obstetricians & Gynaecologists’ national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour.

Eligible babies include all term babies (at least 37+0 weeks of gestation) born following labour, who have one of the following outcomes:

Intrapartum stillbirth: when a baby was thought to be alive at the start of labour and was born with no signs of life.

Early neonatal death: when a baby dies within the first week of life (0-6 days) of any cause. Potentially severe brain injury diagnosed in the first seven days of life, when a baby:

  • was diagnosed with grade III hypoxic ischaemic encephalopathy (HIE) or
  • was therapeutically cooled (active cooling only) or
  • had decreased central tone and was comatose and had seizures of any kind.

The defined criteria for maternal death investigations are:

Maternal death: death of a mother while pregnant or within 42 days of the end of the pregnancy (which Includes giving birth, ectopic pregnancy, miscarriage or termination of pregnancy), from any cause related to or aggravated by the pregnancy or its management, and not from accidental or incidental causes.

  • Direct: deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above. This excludes cases of suicide.
  • Indirect: deaths from previous existing disease or disease that developed during pregnancy and which was not the result of direct obstetric causes, and which was aggravated by the physiological effects of pregnancy in the perinatal period (during or within 42 days of the end of pregnancy).

HSIB will look into all clinical aspects of the incident and gather evidence. They will also interview anyone relevant to a case, which will generally include the patient, their family and NHS staff and clinicians, and will provide a written report once their investigations are concluded.

Health Service Safety Investigations Body (HSSIB)

As part of the NHS Trust Developmental Authority which is responsible for overseeing the performance management and governance of NHS Trusts, HSIB is not truly independent and therefore, The Health Service Safety Investigations Bill creates a new independent arms-length body, which will be called the Health Service Safety Investigations Body (HSSIB).

However, the Government has confirmed that the maternity investigation programme for local investigations, undertaken by the investigation branch, should not be part of the new body’s remit. This does then raise the question of how will these maternity investigations be managed in the long term, and will the loss of the HSIB’s powers hinder thorough investigation, lesson learning and the prevention similar incidents from happening again?

Clinical Negligence claim

If you believe that you have suffered negligent care from maternity services you do not have to wait for a completed HSIB report to seek legal advice. Safety recommendations are not necessarily indicative of medical negligence.

You can contact a member of the team for free advice on 0113 346 4044 or

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