The Well being Providers Security Investigations Physique (HSSIB) has shared insights into security issues raised by girls, households, and different stakeholders about maternity and neonatal care inside NHS England, highlighting the necessity for significant change.
On 23 June 2025, the Secretary of State for Well being and Social Care introduced a nationwide maternity and neonatal providers investigation. The intention is that the investigation might be speedy, system-wide, and reported in December 2025. The Authorities has indicated a dedication to uncovering failings at scale, standardising oversight, and enhancing affected person security throughout the nation.
In spring 2025, HSSIB undertook an exploratory evaluate of maternity and neonatal providers, intending to make use of the data it collected to tell potential areas for investigation. The restricted insights gathered have now been shared to help the broader nationwide investigation.
The HSSIB evaluate paints a stark image of systemic vulnerabilities that expose sufferers to avoidable hurt. From October 2023 to June 2025, HSSIB obtained 35 security issues associated to both maternity or neonatal providers, highlighting recurring points with communication, threat escalation, and adherence to medical pointers.
Solely 35 issues have been reported in an 18-month interval, which appears a really small quantity in comparison with all of the studies of hurt to girls and infants, a incontrovertible fact that HSSIB accepts. Nonetheless, from our expertise as medical negligence attorneys, that is solely the tip of the iceberg.
A stage of disillusionment amongst stakeholders, together with sufferers, clearly exists relating to the flexibility to deliver concerning the required change, however a long time of inquiries and investigations. To counteract this disillusionment, HSSIB considers that any investigation must evaluate the boundaries to implementation.
Systemic failures
As acknowledged above, the evaluate highlights recurring points with communication, escalation of threat, and adherence to medical pointers. From a authorized perspective, these will not be merely operational shortcomings – they’ll level to potential breaches of the obligation of care owed to moms and newborns. Instances the place warning indicators are missed or crucial choices delayed could give rise to claims of negligence, significantly the place hurt might have been anticipated and prevented with acceptable therapy.
Affect on households and evidential issues
The report’s emphasis on affected person hurt – starting from avoidable accidents to tragic fatalities – underscores the very human price of those errors.
Skilled accountability and institutional tradition
Maybe essentially the most regarding from a authorized perspective is the indication of cultural and structural boundaries that inhibit well timed escalation.
Accountability shouldn’t be restricted to particular person clinicians; establishments could also be liable for failing to implement sturdy security measures.
Nationwide investigation: context and implications
The Authorities’s nationwide maternity and neonatal investigation displays the seriousness of the systemic failings highlighted within the HSSIB evaluate. This nationwide investigation goals to supply a complete, nationwide image of maternity and neonatal security, standardise oversight and determine areas for reform. From a medical negligence perspective, this demonstrates that the problems uncovered will not be remoted incidents however a part of a broader nationwide sample that has been ongoing for many years.
Fast evaluate: urgent classes for security
As well as, the speedy evaluate introduced by Wes Streeting focuses on pressing, high-priority classes from maternity and neonatal care. Whereas smaller in scale than the nationwide investigation, it’s designed to flag instant dangers and advocate swift enhancements. From the authorized perspective, its findings might affect requirements of care and assist to bolster claims the place hurt might have been averted. Though solely a short-term evaluate, it underscores the continuing recognition by the Authorities that affected person security failures stay a crucial concern.
A historical past of inquiries and persevering with hurt
Over the previous twenty years, a number of high-profile investigations, together with the Ockenden Overview, the East Kent Maternity Overview, and quite a few Belief-specific inquiries, have repeatedly uncovered critical failings in maternity and neonatal providers. Regardless of these repeated examinations and the suggestions that adopted, HSSIB’s newest findings verify that avoidable hurt persists. Delays and missed warning indicators, communication failures, and poor escalation proceed to hazard moms and infants, highlighting that systemic change stays incomplete.
Conclusion – trying forward
Whereas the critiques are positioned as studying and system enchancment instruments, they inevitably form the panorama and context of medical negligence claims. Furthermore, the report reinforces the necessity for proactive steps by healthcare suppliers to mitigate threat. Sadly, the continuing failure to take action could have each medical and authorized penalties. The HSSIB evaluate, along with the nationwide maternity and neonatal investigation, is to our thoughts a sobering reminder that, regardless of ongoing efforts to enhance care, systemic failings persist. Guaranteeing accountability, whereas advocating for safer requirements of care, stays paramount.
concerning the authors
Sharon joined the Medical Negligence and Private Damage crew as a Authorized Director, in 2024, having beforehand been a Senior Affiliate on the agency between 2005 and 2016.
Asha is a Trainee Solicitor presently in her second seat with the Medical Negligence & Private Damage crew. Asha joined Kingsley Napley in September 2024.