I wish to inform the house of the Government’s plans to establish a Special Health Authority under secondary legislation to continue the Maternity Investigation Programme which is currently a function the Healthcare Safety Investigation Branch.
Plans to establish the Health Services Safety Investigations Body as a Non-Departmental Public Body are contained in the Health and Care Bill 2021. The Health Services Safety Investigations Body will take forward the work of the current Healthcare Safety Investigation Branch’s national programme once fully operational (expected to be April 2023). The scope of the Health Services Safety Investigations Body’s investigations in the Bill does not include the current Healthcare Safety Investigation Branch’s Maternity Investigations Programme. This is because conducting investigations under ‘safe space’ is a key element of the new Health Services Safety Investigations Body. The Maternity Investigation Programme investigations do not follow ‘safe space’ principles.
The Healthcare Safety Investigation Branch became responsible for conducting independent investigations relating to intrapartum stillbirth, early neonatal death, or severe brain injury diagnosed in the first seven days of life and also maternal deaths (approx. 1,000 every year) on 1 April 2018. In 2020-21, the Maternity Investigation Programme completed 1,024 reports and made more than 1,500 safety recommendations to individual NHS trusts addressing a wide array of issues.
The Government considers that independent, standardised, family-centred investigations should continue beyond April 2023 once the new Health Services Safety Investigations Body is established. The new Special Health Authority will:
- provide independent, standardised, and family-focussed investigations of maternity cases that provide families with answers to their questions about why their loved ones died or were seriously injured;
- provide learning to the health system at local, regional and national level via reports for the purpose of improving clinical and safety practices in Trusts to prevent similar incidents and deaths occurring;
- analyse the incoming data from investigations to identify key trends and provide system-wide learning in these areas including identifying where improvements are being made or there is lack of improvement;
- be a system expert in standards for maternity investigations and support Trusts to improve local investigations; and
- collaborate with system partners to escalate safety concerns and share intelligence.
The Special Health Authority will be established for up to five years from 2022-23 to enable maximum learning to be achieved and to equip NHS Trusts with the expertise, resources, and capacity to take on maternity safety incident investigations in the future.
Learning from these investigations is key for meeting the Government’s commitment to ‘make the NHS the best place in the world to give birth through personalised, high-quality support’; and our National Maternity Safety Ambition to halve the 2010 rates of stillbirths, neonatal and maternal deaths and brain injuries in babies occurring during or soon after birth by 2025.
This statement has also been made in the House of Lords