NHS England is launching a first-of-its-kind maternity safety signal system (MOSS) designed to identify worrying trends early and trigger urgent safety checks, helping prevent harm to mothers and babies
Mothers and babies in England are set to benefit from safer care thanks to a new national safety tool. The Maternity Outcomes Signal System (MOSS) will continuously analyse routinely recorded maternity data to detect patterns, such as rising rates of adverse events, that could indicate emerging safety issues. This proactive approach aims to reassure families and staff that risks are being identified early, helping prevent serious incidents before they occur.
MOSS spots potential safety concerns in pregnancy units
The MOSS tool rapidly analyses data routinely recorded by maternity teams on wards to spot potential emerging safety concerns. If the system detects a pattern or trend in the data, it will send a warning signal to trigger a safety check on the unit. This support aims to make staff feel confident in their ability to act swiftly, reinforcing trust in the safety system across all maternity services in the country, seven days a week.
Once the signal is created, the maternity unit must conduct critical safety checks within eight working days and share the findings with national teams, including the Integrated Care Board (ICB). These signals will be traffic-light coded, with amber alerts representing 95% confidence and red alerts representing 99% confidence that the increase in events is real and warrants urgent attention.
Duncan Burton, Chief Nursing Officer for England, said:“There have been too many times where safety issues in maternity could have been detected earlier, and we have seen the devastating impact this has had on families.
“Having a signalling system for maternity which can carefully look at data in near real-time and spot early warning signs if something is potentially going wrong will help to avert safety incidents and prevent tragedies.
“It is the first national system of its kind in maternity to be able to signal potential safety issues as they emerge and allow them to be acted on faster by maternity services.
“And it will be the responsibility of staff in maternity services and hospital’s board executives to urgently act on warning signals so problems can’t be ignored or delayed.”
Improving NHS maternity care
The NHS created MOSS as a direct response to the ‘Reading the Signals’ report, which followed the independent investigation led by Dr Bill Kirkup on maternity and neonatal services in East Kent. It was recommended that a system that could “identify valid maternity and outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory use”.
Dr Bill Kirkup said:“This is a really positive development that originated directly from the investigation into East Kent maternity services. The families there who did so much to bring this to light deserve great credit for the improvements it will bring.”
Health and Social Care Secretary Wes Streeting said: “For the past 18 months, I have met with bereaved and harmed families across the country who have lost babies or suffered serious harm during what should have been the most joyful time in their lives.
“What these families have experienced is deeply upsetting – painful stories of loss, trauma, and a lack of basic compassion. For too long, maternity warning signs have been missed.
“Now, this is a key step we are taking to improve maternity care. We have a sophisticated early warning system that will sound the alarm when patterns emerge that need urgent attention. Every signal will be visible from ward to boardroom, and every signal will be investigated.
“Alongside this, the rapid national investigation will also help us deliver long-lasting change to maternity and neonatal care across the country, and I am setting up a maternity and neonatal taskforce to ensure this change is delivered.
“We are making sure failures of the past cannot be repeated, and that every mother and baby receives the safe care they deserve. I will do everything in my power to ensure no family has to suffer like this again.”
Clea Harmer, Chief Executive, said: “Early detection of serious safety issues is vital in saving babies’ lives, so it’s very important that all maternity services have access to this data and that boards have oversight and act swiftly on any concerns flagged by the Maternity Outcomes Signal System (MOSS).
“This rollout is a welcome step to improve safety monitoring across NHS maternity services, and it’s encouraging to see recommendations from Reading the Signals being implemented, reinforcing the importance of learning from data to drive continuous improvement in maternity safety.”
