HSSIB Review Exposes NHS Maternity Failures

Jodi Newton

Patient safety body HSSIB publishes exploratory review of maternity and neonatal services

As Head of Paediatric and Birth Negligence cases in Osbornes’ Medical Negligence Department, I have been following closely the highly publicised national rapid maternity investigation announced by Wes Streeting MP in June 2025.

On 19 August 2025, the Healthcare Safety and Surveillance Investigation Body (HSSIB) published its latest report, An Exploratory Review of Maternity and Neonatal Services. The report presents findings from a spring 2025 review, which included meetings with 17 stakeholders, analysis of 35 safety concerns submitted to HSSIB, and a review of a 2021 report by the former Healthcare Safety Investigation Branch (HSIB).

The HSSIB report is expressed to have been written with the intent of providing guidance and insight which it hopes will assist the Secretary of State for Health and Social Care’s forthcoming national investigation into maternity and neonatal services, announced in June 2025.

This initiative by the government, known as the national rapid maternity investigation and led by Baroness Valerie Amos, appeared to project itself as an innovative, conscientious and fresh initiative by the government to turn around repeated failures in NHS maternity care. However, for those whose work is in the field of maternity safety, while we recognise the continued dedicated work of the obstetricians and midwives in caring for parents and babies and in seeking to safeguard healthy outcomes, the news of yet another review seemed far from fresh or new. There are reports of patients responding that it was doomed to fail. We expect that the pessimism arises among clinicians, patients, and the patient safety experts as a consequence of having seen so many reviews, albeit with different labels and objectives, over the decades with exciting and well-meaning recommendations, failing to be implemented.

To substantiate this concern, neonatal deaths and stillbirth rates have stagnated staying at a similar level between 2010 and 2022 despite government ambitions via The National Maternity Safety Ambition published in 2015 and driven by Sir Jeremy Hunt MP, committing to reduce the number of brain injuries in babies, stillbirth and neonatal deaths by 50% by 2025.

Patient safety ambitions are vital in triggering continued will to create and sustain a culture of maternity safety which is intended to lead to improved health outcomes. Delivering on this seems far from simple. It is reliant upon compliance from staff, leaders and management at NHS Trusts both at a local and national level.

It seems that therefore the intention of the latest exploratory review by HSSIB is to inform the government about already established key concerns revealed by the multiple investigations which have already passed. The areas which they have recommended require further investigation included:

• National structures responsible for providing direction and oversight of maternity services
• Local governance arrangements and their relationship with national bodies
• Standards and approaches to local investigations when adverse events occur
• Education, training, and professional standards for clinicians in maternity and neonatal care

It then went on to identify themes they consider to have arisen via interviews with stakeholders including:

• The more positive finding that progress had been made in maternity and neonatal outcomes, staffing levels and governance arrangements.
• Overly complex maternity and neonatal systems.
• Inconsistent and varied national collaboration responses and efforts.
• Local governance of maternity operating in isolation and with poor co-ordination with national maternity policies.
• A lack of awareness in identifying and responding to clinical risks.
• Under-delivery in maximising potential to learn from patient safety incidents.
• An observation that the harm suffered by patients can be compounded by the way they are treated following an incident which can lack compassion and with a focus by some on reputation management which impedes the willingness of staff to be transparent and apologise and a system which is too adversarial and defensive.
• Compounded harm for staff following reduced public confidence caused by high profile investigations, and which is also damaging to the confidence of the professionals and making it difficult to recruit.
• Health inequalities in association with ethnicity, social class and deprivation.
• Concerns about standards of training for professionals and a lack of continuing education and training, a toxic culture between staff, and a lack of prioritising of standards. There are reports of poor integration of international trained midwives.

It seems that the frustrations are felt not only by patients but by clinicians and management that patient safety investigations are not delivering solutions which are implemented effectively and with the desired longevity. The rapid national maternity review team now have the benefit of HSSIB’s exploratory review and recommendations to help shape this important development and to boost the chances of a more effective outcome finally being achieved.

A family’s story

The urgency for meaningful reform in maternity care is underscored by real and tragic cases, such as the recent stillbirth case handled by Nicholas Leahy, Senior Associate at Osbornes Law, who secured justice for the parents, highlighting the very systemic failures now under national scrutiny. You can read the full story here.

How can we help?

At Osbornes Law, we understand the deep emotional and physical impact that failures in maternity care can have on families. As the national rapid maternity investigation unfolds, our commitment is to ensure that the voices of affected families are heard and that meaningful improvements are not just promised, but delivered. If you or a loved one have been affected by maternity or neonatal negligence, we are here to help you seek justice and ensure your voice contributes to the push for safer, more accountable maternity care. Please contact us by:

• Filling in our online enquiry form; or
• Calling us on 020 7485 8811