Maternity and Newborn Safety Investigations (MNSI)

What Maternity and Newborn Safety Investigations (MNSI) does

Maternity and Newborn Safety Investigations (MNSI) is a statutory programme that conducts independent, no-blame safety investigations into qualifying maternity and newborn incidents across NHS-funded care in England. Its mandate covers intrapartum stillbirths, early neonatal deaths, potential severe brain injuries diagnosed in the first seven days of life, and maternal deaths during pregnancy and up to 42 days after pregnancy ends. The programme operates under the Care Quality Commission (maternity and Newborn Safety Investigation Programme) Directions 2023, having transferred from NHS England (formerly the Healthcare Safety Investigation Branch) on 1 October 2023. MNSI is funded by the Department of Health and Social Care, headquartered at 2 Redman Place, London, and deployed through four regional teams (North, Midlands and East, London, South) covering approximately 130 NHS trusts. Investigations are conducted using human factors and safety science methodologies, producing safety recommendations rather than attributing individual blame.

The programme's core technical offering is the Investigation Programme, supported by three published methodology tools: the Health Equity Warning Score (HEWS) and Health Equity Assessment and Resource Toolkit (HEART) introduced in December 2024 for systematic health-equity consideration in investigations, and the COMPASS (Culture of Organisations and its iMpact on PAtientS' Safety) cultural assessment tool piloted in 2025 with a second pilot in 2026. Outputs include Safety Spotlights, thematic reviews, annual reports, and briefing papers distributed to NHS trusts and published on the programme's website. Revenue mechanics are entirely non-commercial: MNSI is publicly funded, provides services at no cost, and is mandated to receive referrals; it has no pricing model, no paying customers, and no venture or private ownership. Strategic influence extends into national policy through MHRA device safety actions and clinical-society guidance citing MNSI findings.

Name

Maternity and Newborn Safety Investigations (MNSI)

Legal name

Maternity and Newborn Safety Investigations (MNSI) programme

Website

https://mnsi.org.uk

Company type

Private

Founded year

2018

Operating status

Operating

Headcount range

51–100 employees

Short description

MNSI is a UK government statutory programme that conducts independent, no-blame safety investigations into qualifying maternity and newborn incidents across all NHS trusts in England, funded by the Department of Health and Social Care and hosted by the Care Quality Commission.

Ownership category

akta.pro rank

Product category

Healthcare Safety Investigations

NAICS

Offices of All Other Miscellaneous Health Practitioners (621399)

SIC

Services-Misc Health & Allied Services, Nec (8090)

akta.pro primary industry

Maternal, Newborn & Child Health (MNCH) Programs (BPADAIAC)

akta.pro secondary industries

Maternal, Newborn, Child & Adolescent Health (MNCAH) NGOs (HLAJAKAG), Maternal, Neonatal & Pediatric Remote Monitoring (HLACAPAG)

Keywords

• Maternity safety investigations
• Patient safety investigations
• Healthcare safety science
• No-blame investigations
• Neonatal safety monitoring

Headquarters

HQ city

London

HQ country

United Kingdom

HQ region

Europe

Offices1 record

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Operations, Infrastructure, Technology or R&D, Others

Revenue model

1. Government Funding: MNSI is funded by the Department of Health and Social Care and hosted by the Care Quality Commission (CQC) as of 1 October 2023. Previously it operated under NHS England. The programme operates as a statutory investigation body mandated to investigate qualifying maternity safety incidents across NHS trusts in England.

Distribution channels3 records

Marketing channels7 records

Core offering

MNSI conducts independent, no-blame safety investigations into qualifying maternity and newborn patient safety events across NHS-funded care in England, including intrapartum stillbirths, early neonatal deaths, potential severe brain injuries, and maternal deaths. The programme produces safety recommendations, learning reports, and thematic reviews to improve maternity services nationally, using human factors and safety science methodologies. All NHS trusts in England are statutorily required to report qualifying events to MNSI.

Product overview

MNSI is a national investigation programme (not a traditional product company) providing independent maternity and newborn safety investigations across NHS England. The core offering is the Investigation Programme, which examines qualifying maternity incidents including intrapartum stillbirths, early neonatal deaths, potential severe brain injuries, and maternal deaths. Supporting tools include the Health Equity Warning Score (HEWS) and Health Equity Assessment and Resource Toolkit (HEART) launched in December 2024, and the COMPASS cultural assessment tool. MNSI publishes findings through Safety Spotlights, thematic reviews, annual reports, and briefing papers. The programme operates across all NHS trusts in England through four regional teams.

Differentiator

Problem solved

Functional benefit

Products and services

• MNSI Investigation Programme Independent maternity safety investigation programme for NHS-funded care across England, investigating intrapartum stillbirths, early neonatal deaths, severe brain injuries, and maternal deaths to provide learning and safety recommendations without attributing blame.
• Health Equity Assessment and Resource Toolkit (HEART) Interactive PDF toolkit providing prompts, question banks, and evidence repository to help investigators systematically consider health equity factors including protected equality characteristics and health determinants in maternity investigations.
• Health Equity Warning Score (HEWS) Scoring tool to classify a person's risk of experiencing barriers to health equity by considering protected equality characteristics and health/social factors that may have impacted care and outcomes.
• Safety Spotlights Published learning documents sharing investigation findings and safety recommendations on specific topics including equipment issues, clinical practices, and communication gaps to improve maternity safety.
• COMPASS Programme Culture of Organisations and its iMpact on PAtientS' Safety (COMPASS) - assessment tool designed to examine the impact of organisational culture on safe maternity care.
• Annual Reports Annual publications documenting MNSI activities, findings, safety recommendations, and work to improve maternity and newborn safety across NHS England.
• NHS Trust Investigation Coverage MNSI investigation services covering all NHS trusts in England, organised across four regions (North, Midlands and East, London, South) with dedicated teams for each area.

Quantifiable outcome

• MNSI investigations lead to safety recommendations that improve maternity services nationally

Named customers1 record

Segments3 records

Ideal customer profiles1 record

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Partnerships

One partnership is on record.

• Care Quality Commission (CQC)coreStrategic or Co-development Partner · 1 October 2023MNSI transferred from NHS England to being hosted by the Care Quality Commission (CQC) on 1 October 2023. The programme operates under CQC Directions 2023 and maintains independence in investigation conduct and reporting. MNSI shares safety concerns with CQC's regulatory and enforcement teams and information sharing follows a formal agreement.

Scale indicators4 records

Recent moves8 records

Expansion highlights5 records

Broad incumbents

• Care Quality Commission (CQC): MNSI's host organisation since 1 October 2023 and the statutory regulator of health and adult social care providers in England. CQC is the broader incumbent that oversees MNSI's investigations and can act on safety findings, making it the most relevant umbrella peer in the same regulatory/policy domain.
• NHS England: MNSI's former host organisation (until 1 October 2023) and the broader commissioner/overseer of NHS services in England. A direct institutional peer in the sense that it houses the residual HSIB directorate and shapes national safety policy, and remains the dominant force in NHS maternity commissioning.

Others

• Medicines and Healthcare products Regulatory Agency (MHRA): The UK regulator for medicines and medical devices that has acted directly on MNSI findings (e.g., the blood transfusion set Device Safety Information). Operates in the same patient safety domain and is a downstream actor that converts MNSI recommendations into regulatory action.
• Royal College of Obstetricians and Gynaecologists (RCOG): The professional body that ran the original Each Baby Counts programme (now inherited by MNSI) and continues to drive national maternity safety through clinical guidelines, training, and the Each Baby Counts Learn & Support programme. Operates in the same maternity safety ecosystem, with overlapping datasets and stakeholders.

Direct peers

• NHS Resolution: The NHS arm's-length body that handles clinical negligence claims and the Early Notification scheme for maternity incidents. Operates alongside MNSI in the maternity safety space — when an incident occurs, NHS Resolution handles the compensation side while MNSI handles the systemic investigation, making it a closely related peer in the same value chain.
• Healthcare Safety Investigation Branch (HSIB): The non-maternity arm of the original HSIB, now operating as a directorate of NHS England. MNSI was the maternity/neonatal programme within HSIB until 2023, making HSIB the closest direct functional peer — both are independent, no-blame safety investigation bodies operating within the NHS England ecosystem.

Regional players

• Healthcare Safety Investigation Unit (Northern Ireland): Northern Ireland's patient safety investigation function, which sits separately from MNSI's England-only remit. Comparable function (independent safety investigation) but narrower geographic scope and lower public profile, making it a smaller regional peer in the same UK safety ecosystem.
• Healthcare Improvement Scotland: Scotland's equivalent NHS quality and safety improvement body. Comparable in function (independent safety review, national learning) but operates in a separate UK jurisdiction, making it a regional peer that faces similar mandate and methodological questions around no-blame investigation.
• Australian Commission on Safety and Quality in Health Care: Australia's national body for healthcare safety and quality, including incident investigation and national standards. Closest international peer to MNSI's mandate — comparable in scope (national safety oversight, system-level learning, no-blame principles) but operating under a different healthcare system and geography.
• Danish Patient Safety Authority: Denmark's national authority for patient safety, with a statutory mandate to investigate adverse events using a no-blame approach similar to MNSI's. Operates as a national-level safety investigation body, providing a strong international peer despite the different country and health system.

Market position

Strengths4 records

Weaknesses5 records

Competitive moat4 records

Key risks6 records

Key highlights6 records

Customer concentration

• Xx.com/MNSI_UK
• LinkedInlinkedin.com/company/maternity-and-newborn-safety-investigations

Compliance2 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles2 records

Funding overview

Funding rounds

Investors

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M&A

Investments

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Frequently asked questions about Maternity and Newborn Safety Investigations (MNSI)