To ask the Secretary of State for Health and Social Care, with reference to the Report of the Morecambe Bay Investigation by Dr Bill Kirkup, published in March 2015, what steps his Department has taken to (a) draw up clear standards for incident (i) reporting and (ii) investigation in maternity services and (b) introduce mandatory (A) reporting and (B) investigation of (1) maternal deaths, (2) late and intrapartum stillbirths and (3) unexpected neonatal deaths.
In July 2019, NHS Improvement published a new NHS Patient Safety Strategy. The strategy commits the National Health Service to developing a new Patient Safety Incident Response Framework (PSIRF), which will replace the Serious Incident Framework (published in March 2015) and support clinicians to identify insights at the point of care.
In April 2018, the Healthcare Safety Investigations Branch (HSIB) began rolling out its new maternity investigation approach, which investigates cases of unexplained severe brain injury, term intrapartum stillbirths and early neonatal deaths (all cases notifiable to the Royal College of Obstetricians and Gynaecologists under the 'Each Baby Counts' programme) and maternal deaths in England. Since 1 April 2019 HSIB has completed its roll out of investigations to all 130 trusts with maternity services in England.