Dr Rosie Benneyworth, Interim Chief Executive at HSSIB, said: “Baroness Amos’s investigation highlights the urgent need for clearer accountability across maternity and neonatal care. Women, babies and families need to know that when harm happens, it will be understood fully, responded to openly and used to drive meaningful change.
“Accountability should not be reduced to blame. It should mean clear responsibility for recognising risks, acting on learning and making sure improvement is followed through at local, regional and national level.
“As an independent body, HSSIB acts as a centre of excellence for safety investigation. Our independence and safe space powers help create the conditions for candour, learning and evidence-based insight, so the system can move beyond defensiveness and support safer care for women, babies and families.”
The report describes a system in which families have too often experienced harm without clear answers or confidence that learning will be acted on. It shows that accountability must include understanding why harm was able to happen, who is responsible for acting on learning and how improvement is overseen so that risks are not repeated.
These findings align with HSSIB’s exploratory review of maternity and neonatal services, which identified an overly complex system where oversight responsibilities are spread across multiple organisations, investigation approaches vary, families are not always listened to, and learning is not always embedded.
Our work consistently highlights the urgent need for health services to develop effective safety management systems: structured, proactive approaches to identifying and managing risk, integrating learning into practice, and ensuring action is taken and sustained over time.
HSSIB will continue to work with partners to support effective patient safety investigation and learning, strengthen safety investigation capability across the NHS and provide independent insight to improve maternity and neonatal care.
Read the Independent National Maternity and Neonatal Investigation report
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