A new role being piloted in Gloucestershire is supporting families who have experienced an adverse outcome during their maternity or neonatal care.

The Maternity and Neonatal Independent Senior Advocate (MNISA) will ensure the voices of families who have experienced an adverse outcome are listened to, heard, and acted upon by their maternity and neonatal care providers.

An adverse outcome is a serious incident or outcome that requires further investigation, such as:

  • A baby died before they were born, after 24 weeks of pregnancy.
  • A baby died within 28 days of birth.
  • A baby was diagnosed with a brain injury, or this was suspected.
  • The baby’s mother or birthing parent has died.
  • The baby’s mother or birthing parent had an unexpected or unplanned removal of their womb, within 6 weeks of giving birth.
  • The baby’s mother or birthing parent had an unexpected admission to the critical or intensive care unit.

Maternity and Neonatal Independent Senior Advocates can support women, birthing people, and families by providing support, helping them understand the maternity and neonatal healthcare system, attending follow up meetings where concerns about their care are being discussed, and supporting them through investigation and complaints processes. There are no time limitations, so it does not matter whether they received care recently, or some time ago.

The role is independent from NHS Trusts, and reports to NHS Gloucestershire Integrated Care Board (ICB), who are responsible for planning and buying services in the county.

The role was developed by NHS England following the Ockenden review into maternity care at Shrewsbury and Telford Hospital Trust and co-produced by families and staff. The pilot will run until at least March 2025 and it will be evaluated by NHS England before next steps are decided.

Joanna Garrett has been appointed as the new Maternity and Neonatal Independent Senior Advocate for Gloucestershire, and has worked in healthcare for over 15 years in a variety of roles.

Joanna says:

“I have lots of experience of caring for and supporting patients and families in often complex and challenging situations. I am committed to supporting families who have experienced an adverse outcome and support them to have their voices heard.”

Dawn Morrall, Assistant Director of Midwifery at NHS Gloucestershire Integrated Care Board says:

‘’While adverse outcomes in maternity care, such as brain injury or death for a mother or baby, are very rare, the investigation processes which follow can sometimes be difficult for families to navigate. It is vital that families are supported to ask questions about their or their babies care, and that they are listened to and heard by their maternity and neonatal care providers.”

“This new pilot led by NHS England will provide an advocate who can help families navigate the processes and signpost them to the best support available, and we are pleased to be one of the first areas in the country to have this important bespoke role in our community.”

Lisa Stephens, Director of Midwifery at Gloucestershire Hospitals NHS Foundation Trust says:

‘This pilot will provide families with the independent support and guidance that is so important. This work will continue to improve the way we listen to women and families where they have had an adverse outcome, and learn from their experiences.’’

Additional information

People do not need to be sure if there were mistakes or negligence in the mother or baby’s care to ask for support from an MNISA, there is no charge for any support given, and interpreters can be made available if needed.

Families can contact a Maternity and Neonatal Independent Senior Advocate through an online referral form. They can also call, email, or write if preferred. Health and care staff can also request that the Maternity and Neonatal Independent Senior Advocate makes contact with someone, with their permission.

For more information and the referral form, visit www.nhsglos.nhs.uk/link/maternityadvocacy.