Written evidence submitted by Sands and Tommy’s Joint Policy Unit (PSN0023)


The Sands and Tommy’s Joint Policy Unit is focussed on achieving policy change that will save more babies’ lives during pregnancy and the neonatal period and on tackling inequalities in loss, so that everyone can benefit from the best possible outcomes.

We welcome the opportunity to make a written submission to inform the Health and Social Care Committee’s Independent Expert Panel in their evaluation of public inquiry/review recommendations on patient safety which have been accepted by the Government.

We have provided responses to recommendations that the committee is evaluating in the following three areas:

-          Maternity care and leadership

-          Training of staff in health and social care

-          Culture of safety/whistleblowing



Policy area - Maternity care and leadership

Recommendation 1: “There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in our view no less applicable to maternal and perinatal deaths, and should have raised concerns in the University Hospitals of Morecambe Bay NHS Foundation Trust before they eventually became evident. Legislative preparations have already been made to implement a system based on medical examiners, as effectively used in other countries, and pilot schemes have apparently proved effective. We cannot understand why this has not already been implemented in full, and recommend that steps are taken to do so without delay.” (Morecambe Bay Investigation, 2015)

Importance of reviews and investigations following the death of a baby

When serious incidents occur, it is important to have an independent, standardised method of investigating. The National Perinatal Mortality Review tool (PMRT) supports objective, robust and standardised hospital reviews of care. The Maternity and Newborn Safety Investigations (MNSI) programme (formerly the Healthcare Safety Investigation Branch (HSIB), carries out independent investigations of maternity and neonatal incidents, meeting certain criteria.

Perinatal Mortality Review Tool (PMRT)

The PMRT provides the framework to enable hospitals to undertake high quality, consistent reviews into their own care. To meet the requirements of the Maternity Incentive Scheme, Trusts in England are required to use the PMRT to review perinatal deaths and create action plans for improvement.


Quality of reviews:

standardisation and permanent physical or digital designs to eliminate human error”.


Engaging families in reviews:

reviews sought parents’ perspectives in 2022-23, compared to 75% in 2018-19. The graph below shows parents’ engagement has steadily increased over time, however, there has been a decline in the number of reviews with parents’ comments recorded:

Sharing learnings from the PMRT:

As well as providing answers to parents and families, it is vital that the learnings from reviews and investigations are shared and acted upon, to prevent avoidable deaths in the future. In addition to being used at board level, insight from reviews must be used nationally. Currently, information from the PMRT does not feed into a wider national system for improving safety. The recent investigations into maternity services at Shrewsbury and Telford and East Kent Trusts have highlighted that there is still a way to go in organisations holding themselves to account for the action they are taking to learn from serious incidents.


HSIB reviews (now MNSI)

In 2018, HSIB established its maternity programme to conduct independent and standardised investigations into maternity care. In October 2023 this became the Maternity and Newborn Safety Investigation programme (MNSI) which is hosted by the Care Quality Commission.

Findings from evaluations:


It is essential that concerns are addressed in the move to the MNSI programme hosted by the CQC. In particular that reviews are robust, engage compassionately and effectively with families, and ensure robust actions are taken when issues in care identified. It is essential that recommendations made following a review are followed up and audited to ensure necessary changes have been made.

The pandemic highlighted the fragility of many core safety initiatives, with Maternity Transformation Programme initiatives being suspended. MBRRACE notifications of deaths were not made in a timely way and reviews following the death of a baby were not carried out. It is important that we learn lessons from the pandemic and the vulnerability of safety initiatives to be dropped during times of crisis.

Coronial investigations and the crisis in perinatal pathology


In 2019 the Ministry of Justice and Department of Health and Social care jointly ran a public consultation on the coronial investigation of stillbirths. A factual summary of the consultation responses was published in December 2023, which stated that the government was still exploring the issues raised as well as ongoing issues which impact on decisions whether to take forward proposals in the short term, including the current crisis in perinatal pathology.


There is an urgent need to address the crisis of perinatal pathology in England, as discussed in this briefing on the issue from Sands. Currently, a significant proportion of parents must wait over three to six months for their baby’s post-mortem to be undertaken and for the results to be communicated to them. This is having a devastating impact on parents, leaving them in distressing limbo, unable to move on with their grief, and lacking important information which can determine difficult decisions about another pregnancy.

The shortage of perinatal pathologists has been growing over decades. In most recent years mutual aid between pathology centres reduced the impact on national delivery of services, but that approach is breaking down as overburdened centres have dwindling capacity to pick up cases beyond their own area.


Some initiatives to improve the situation, including a recruitment drive and plans to use new technologies, are ongoing but will take significant time to have an impact. It is important that the Government provide additional resources and support to ensure that the needs of bereaved parents are being prioritised.



Recommendation 2: A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the code and their employers to enforce it.” (From the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013.)

Trust board responsibility for safety and quality of services

As providers of services, the safety and quality of maternity and neonatal services are ultimately the responsibility of Trust boards. Trust leadership at the executive and board level is reviewed by the CQC during inspections. However, failures in board leadership continue to be identified in reviews and inquiries. The Kirkup review of maternity and neonatal services in East

Kent found that, among other issues, the Trust board missed several opportunities to properly identify the scale and nature of problems and to put them right.

Sands and Tommy’s Joint Policy Unit have recently published a report highlighting issues with the oversight that NHS Trust boards have over the safety and quality of maternity and neonatal services. The aim of this research was to review whether the information presented to boards - and subsequent review and discussion – enabled boards to deliver on their responsibility of ensuring the safety and quality of their service.

Some of the key findings in our report were:



Policy area - Training of staff in health and social care


Recommendation 1: “Targeted interventions on collaborative leadership and organisational values, including a new, national entry-level induction for all who join health and social care.” (From the Health and social care review: leadership for a collaborative and inclusive future report, 2022)

Importance of effective leadership

Effective leadership and oversight from a Trust board is vital to ensure safe and personalised care. This includes taking ownership of the safety of their services, and making sure that their

teams have the relevant skills to provide high quality, compassionate care for mothers and babies.

The interim Ockenden report highlighted the importance of strengthening leadership and oversight for maternity, addressing toxic workplace behaviour and cultures, and fostering collaborative approaches. The leadership team is strongest when the service level manager, midwifery and obstetric leaders are all in place and work well together.

Concerns on leadership from CQC:

CQC reports continue to state issues with governance and lack of oversight from boards, including challenges in identifying issues and packages of support at service delivery level. In their 2021 programme of focussed inspections, some of the maternity services the CQC visited did not have all leaders needed in post, or they were held by interim postholders. The lack of stable leadership may prevent long-term collaboration and leadership development.

There needs to be ongoing commitment to improve leadership, at both a national and board level, as well as clarity over the role of Integrated Care Systems and their Local Maternity and Neonatal Systems in the oversight of the safety and quality of services.



Importance of training

Evidence suggests that regular multiprofessional training in maternity can improve patient outcomes. Sands and Tommy’s Joint Policy Unit published our first progress report in May 2023, bringing together data from different sources for the first time to show the extent of pregnancy loss and baby death across the UK. In a section on training, findings included in the report were:

The MBRRACE confidential enquiries into Black and Asian baby deaths identified a number of key issues along the care pathway, where the quality of care provision differed between the Black, Asian and White groups. These highlight the need for ensuring all women receive personalised care which is sensitive to their individual circumstances. The reports recommended developing training and resources for all maternity and neonatal staff, so they can provide culturally and religiously sensitive care for all mothers and babies.

Safe staffing levels and training

Our progress report also analysed the impact of insufficient staffing on training. Some of the findings were:



Policy area - Culture of safety/whistleblowing

Recommendation 1: “Culture of safety: Every organisation involved in providing NHS healthcare, should actively foster a culture of safety and learning, in which all staff feel safe to raise concerns. Action 1.1: Boards should ensure that progress in creating and maintaining a safe learning culture is measured, monitored and published on a regular basis. Action 1.2: System regulators should regard departure from good practice, as identified in this report, as relevant to whether an organisation is safe and well-led.” (From the Freedom to Speak Up Review, 2015)


Reports have consistently identified safety culture as an issue in maternity and neonatal services, with the Ockenden Report promoting collaboration between maternity and neonatal teams, to improve care and outcomes.

Maternity Incentive Scheme:

The Maternity Incentive Scheme was introduced to support the delivery of safer maternity care. Previous research has found:


Wider concerns around safety of services:

labour and birth, compared to 72% in 2019. 77% of women and birthing people said that if they raised a concern during labour and birth, they felt it was taken seriously - down from 81% in 2017.


Steps should also be taken to ensure that all maternity safety improvement schemes include a focus on tackling inequalities, with action, progress and impact monitored.

Towards a ‘Just Culture’ for safer maternity care

A ‘Just Culture’ supports safe care and is an important element of good bereavement care, by acknowledging that something has gone wrong and committing to understanding why.

Sands have found that the word parents value hearing is ‘sorry’. Currently, professionals may feel awkward saying sorry because it could be interpreted as an admission of liability. However, in UK law (except in Northern Ireland), saying sorry does not mean that you are admitting blame, as explained in this resource created by Sands. Some fear being unfairly blamed, while others focus on issues in the health system which leads them to believe blaming individuals is unfair.

We need a culture that is open and candid, to share what has gone wrong and what needs to improve. The end goal is not accountability or a learning culture, but safer, personalised and equitable care. Regulation, therefore, needs to support an approach which enables improvement rather than apportions blame.


Jan 2024