The government bill on health care, passed Wednesday, means NHS staff can report clinical errors privately in a “safe place”. But Rob Behrens, parliamentary ombudsman and health services ombudsman, says the change means he and his staff will not be able to understand medical failures because his office will be denied access to this vital information. Ironically, the reversal of the rules for health research went through the Commons on the same day that the report on the biggest motherhood scandal in NHS history was published. “We are now virtually excluded from the so-called safe space,” Behrens said. “There is a serious risk that women who have experienced immediate maternity failure will not be able to be accountable for the service as a result of the law change.” Under the changes, the Healthcare Safety Investigation Branch (HSIB), founded in 2017 by then-Secretary of Health Jeremy Hunt to improve patient safety following the Stafford scandal, will be renamed the Health Service Safety Investigations Body ( HSSIB). The new body may collect classified information from midwives, nurses and doctors involved in preventable deaths and patient safety gaps, but this information may not be disclosed to anyone other than medical examiners. “It means that if the new body, the successor to the HSIB, decides to start an investigation into a maternity crisis like the one in Shrewsbury, then it will have the right to get the views of clinicians, without the clinicians being held accountable for what they did. “the evidence they gave to the HSIB,” Behrens said. “And that’s a big concern. It is a breach of responsibility. “The only way we could stop it was to go to the Supreme Court.” He spoke after the final report from the independent NHS investigation at Shrewsbury and Telford Hospital found that 201 babies and nine mothers could have or would have survived if an NHS trust had provided better care. Failures at Shrewsbury could be the tip of the iceberg, Behrens suggests. “We have a significant number of cases not only of health services but also of motherhood. “I looked at a significant number of deaths as a result of perinatal events.” Shrewsbury is not the only one looking at obstetric services from other agencies, with reports later this year to Nottingham University Hospitals and the NHS Institute of East Kent Hospitals, seven years after another maternity scandal was investigated at the General Hospital. Furness in Barrow. “What strikes me is that if you compare the Ockenden report with the 2015 Kirkup report at Morecambe Bay, you have to ask why things happen over and over again when they have to stop after the first example. it happens? “You have politicians who said after Morecambe Bay, ‘This should never happen again.’ And I heard politicians in the House of Commons say exactly the same thing [this week]. But it does. And that is a collective failure. “ Behrens says he was hit by the battle mothers of the battle, such as Rhiannon Davies and Kayleigh Griffiths in Shrewsbury for many years, to get to the truth. “I take my hat off to the integrity and perseverance of those people who have had tragedies and [were] still determined to find out what happened. Years have passed from their lives, and we must respect that deeply. It should not happen. “These women and their families have been disappointed by the shocking levels of obstetric care with devastating consequences. What exacerbates the list of mistakes for many years is that the voices of victims and families were never heard, and even blamed for the results. That’s a shame. “ Behrens added: “This report should be a wake-up call for maternity care services and trusts. I reiterate Donna Ockenden’s view that maternity care should be adequately funded, staff well trained and, when things go wrong, trusts should listen to the people affected and learn from their mistakes. “
