Medical Negligence

Serious Incident Reports (SIRs) and what parents can expect following baby loss

parents holiding baby booties in their hands

Theresa Greenwood

Clinical Support Executive

8 min read time

Whether it happens to be a stillbirth, a consequence of a birth injury or a sudden unexplained death, every baby loss is a tragedy for the family involved and understandably parents will want to seek answers as to why it happened.

Infant deaths are at their lowest since records began but nevertheless 2,226 children aged under one year’s-old died in England and Wales in 2020.

At Hudgell Solicitors our birth injury lawyers help parents get those answers and, if necessary, hold hospitals, doctors and NHS trusts to account.

However, the process of getting answers can be daunting for parents who often feel overwhelmed by the number of reviews and investigations that can be launched following the death of a baby.

Here we help explain the processes of each one and how they can be important in finding out what may have gone wrong.

Pregnancy scan at hospital

What is an NHS Serious Investigation Report (SIR)?

Following the death of a baby, or in the case of a stillbirth, there will always be an NHS Serious Investigation Report. Usually if a baby has died there will be some lessons to be learned on almost 100 per cent of cases.

NHS Investigation Reports can have different names; Serious Incident Reports (SIRs), Root Cause Analysis reports (RCA), Serious Untoward Investigation reports (SUI) and, most recently, a Patient Safety Incident Investigation Report or (PSII).

But, regardless of the name the process is similar, and the reports are produced by Hospital Trusts following an investigation into a serious incident. These reports can highlight:

  • lapses in care
  • lapses in organisational systems
  • identify steps which can be taken in order to prevent similar incidents happening again

If a serious incident is being investigated and a report is being produced, the hospital will contact families to invite them to be involved in the report and the investigation. This is to give the family an opportunity to suggest questions to be answered by the investigation and be involved in the report. They will also give a timeframe of when the report is likely to be completed.

The usual timeframe for completion of reports is 60 working days but hospitals can take longer, and the family should be kept informed of the progress of the investigation. Sometimes any delay in the report is due to the complexity of the investigation.

Investigation Reports can be useful to explain what happened and why, and whether, there were any lapses in the care provided.

If you believe you’ve suffered negligent maternity care contact our pregnancy & birth injury team today.

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I have received an NHS Investigation Report, what do I do next?

For some, the Investigation can successfully lead to a medical negligence claim.

Hudgell Solicitors are regularly contacted by patients and their families when they receive an Investigation Report. We are able to help them understand the report and its findings which can often be complex. We would encourage anyone that has received an Investigation Report to contact us for a confidential and free consultation.

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Listen to Theresa Greenwood’s Podcast: ‘Baby Loss & Investigations’

Other investigations following a baby death or stillbirth include:

Healthcare Safety Investigation Branch (HSIB) Report

A serious investigation may be undertaken by the HSIB which is independent body.

Their maternity investigations look at factors that have harmed or may harm NHS patients. HSIB work closely with patients, families and healthcare staff affected by patient safety incidents, but they do not attribute blame or liability.

The aim of the HSIB is to share learning and to make safety recommendations that improve safety at a national level. The HSIB undertakes around 1,000 independent maternity safety reviews each year and all NHS trusts with maternity services in England refer incidents to the HSIB.

National Perinatal Mortality Review Tool (PMRT) Report

Sometimes babies die because of the quality-of-care mums and babies receive.

An enquiry in 2015 found that in 60 per cent of cases a stillbirth might have been prevented if health professionals had followed national or relevant local guidelines.

The National Perinatal Mortality Review Tool (PMRT) was launched in 2018 and aims to provide answers for bereaved parents and their families about why their baby died.

Healthcare Quality Improvement Partnership says in the last year 3,981 reviews were carried out across the UK and 97% of which identified at least one issue with care (with an average of four issues per death – increasing to five issues per death where the baby was born at term). Other key findings include:

  • Inadequate fetal growth surveillance was identified as relevant in 9% of deaths reviewed, and remains the most common single issue
  • Inadequate investigation or management of reduced fetal movement was the second most common single issue (relevant in 8% of deaths reviewed)

Child Death Review

A Child Death Review must be carried out for all children regardless of the cause of death. This includes the death of any live-born baby where a death certificate has been issued. For the avoidance of doubt, it does not include stillbirths, late fetal loss, or terminations of pregnancy.

A Child Death Review may not happen until 12 months following the death.

The Child Death Review Meeting (CDRM) should be attended by professionals who were directly involved in the care of the child during his or her life, and any professionals involved in the investigation into his or her death.

A Child Death Overview Panel (CDOP) of doctors, other health specialists and childcare professionals consider the information, to try to ascertain what caused the death, what support and treatment was offered to the child and their family up until the death, and what support was offered to the family after the child died.

It is required to consider whether there were any preventable factors that contributed to the death and it decides whether there are any recommendations and actions needed to help prevent similar child deaths in the future.

If you believe you’ve suffered negligent maternity care and want to speak to us, contact our pregnancy & birth injury team today:

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Cases where Hudgell Solicitors successfully represented parents involving an NHS Investigation Report:

Mother who died when pregnant with twins had heart condition

Kelly Forrest was already a mother of three children and made midwives aware of her family history at her first antenatal appointment, where it was recorded in her medical notes. However, due to a ‘memory lapse’ it was not transferred onto the NHS GTrust’s electronic systems.


Doctors treating her were unaware of her family’s medical history and shedied after suffering severe heart failure. Her baby boys survived having being delivered by a Caesarean Section.

A Serious Incident Investigation concluded that the root cause of the incident had been ‘an unintended skill based memory lapse as the patients’ family history was not escalated appropriately or acted upon at any point during her pregnancy’.

Hospital admitted their stillborn baby could have been saved

David and Tracey Church recieved a significant compensation settlement after their son was delivered stillborn – as a hospital trust accepted he could have been saved had an emergency caesarean section been carried out earlier.


A Serious Incident Report by the hospital revealed that despite blood samples being taken shortly after Mrs Church was admitted, they were not checked by a health professional and despite recordings of the baby’s heartbeat also being taken, they were not continuous, and no further action was taken by midwives.

The Trust admitted it failed to monitor the heath of Wendy Pratt’s baby daughter after her 20 week scan revealed her to be smaller than expected.

Hudgell Solicitors are regularly contacted by patients and their families when they receive an Investigation Report. We are able to help them understand the report and its findings which can often be complex. We would encourage anyone that has received an Investigation Report to contact us for a confidential and free consultation.

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What is Birth Negligence?

Birth negligence essentially means mistakes made by health professionals which should not have happened.

Common mistakes seen by our team include maternity staff failing to carry out tests quickly enough during pregnancy, misinterpreting scans leading to an incorrect diagnosis and inappropriate treatment, misinterpretation of fetal heart rate patterns, failure to act upon reduced fetal movements, and failure to take appropriate action when a mother’s blood pressure is raised.

Communication issues can also often be a contributory factor to things going wrong, and we see far too many cases where mothers and their partners feel their concerns have not been listened to early enough, or that they have been ignored completely.

Making a Birth Injury Claim

At Hudgell Solicitors, our team of medical negligence solicitors has extensive experience of handling birth injury claims and our clients often praise us for the sympathetic and understanding approach we take, alongside a determination to ensure we hold people to account and get the answers people need.

If you, your partner or your child has been affected adversely in any way during pregnancy, labour, childbirth or in the immediate aftercare period, whether that was under NHS or private care, our birth injury solicitors and lawyers are here to listen to your experience and provide you with support.

The first step is to get in touch.

You can begin by contacting us via our claim form and selecting Birth Injury.

You can also call us for a confidential discussion of your current situation or arrange a meeting to suit you via our online form.

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Read more: Birth Negligence

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Serious Incident Reports (SIRs) and what parents can expect following baby loss

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