New law means future medical scandals can be missed, says NHS watchdog | health policy



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New laws allowing health professionals involved in medical gaffes in England to secretly testify mean future maternity scandals could be missed, NHS ombudsman has warned, saying ‘shocking’ baby deaths in Shrewsbury not be one-time.

The government’s health and care law, passed on Wednesday, means NHS staff can testify privately about clinical errors in a “safe space”. But Rob Behrens, the parliamentary and health service ombudsman, says the change means he and his staff cannot fathom medical deficiencies because his office will be denied access to that vital information.

In bitter irony, the shakeup of health screening rules slipped through the House of Commons on the same day the report on the biggest maternity scandal in the history of the NHS was published.

“We are now effectively excluded from the so-called safe space,” Behrens said. “There is a serious risk that women directly affected by maternity care failures will not be able to hold the service accountable as a result of the change in law.”

Under the changes, the Healthcare Safety Investigation Branch (HSIB), which was founded in 2017 by then Secretary of Health Jeremy Hunt to improve patient safety following the Stafford hospital scandal, will be renamed the Health Service Safety Investigations Body (HSSIB). The new body can collect classified evidence from midwives, nurses and doctors involved in preventable deaths and patient safety issues, but this information cannot be shared with anyone but coroners.

“It means that if the new agency, as the successor to HSIB, decides to launch an investigation into a pregnancy crisis like the one in Shrewsbury, they have the right to take the opinion of clinicians, without holding clinicians accountable for what they do.” did, in terms of the evidence they gave to HSIB,” Behrens said. “And that’s a big concern. It is a breach of liability. The only way we can stop it is to go to the Supreme Court.”

He spoke out after the final report of the independent inquiry into the NHS trust from Shrewsbury and Telford Hospital found that 201 babies and nine mothers could or would have survived if an NHS trust had provided better care.

Shrewsbury’s shortcomings may be the tip of the iceberg, Behrens suggests. “We have a significant number of not only healthcare cases, but also maternity cases. I’ve looked at a significant number of deaths from perinatal incidents.”

Shrewsbury isn’t alone in getting her maternity care looked into by other agencies, with reports expected later this year at Nottingham university hospitals and the East Kent Hospitals University NHS Foundation Trust, seven years after another investigation was launched. maternity scandal, at Furness General Hospital in wheelbarrow.

“What strikes me is that when you compare the Ockenden report to the 2015 Kirkup report in Morecambe Bay, you have to ask the question why things happen over and over when they should be stopped after the first example of it happens?

“You have politicians after Morecambe Bay who said, ‘This must never happen again.’ And I heard politicians in the House of Commons say the exact same thing [this week]† But it does. And that is a collective failure.”

Behrens says he was struck by the struggles that mothers like Rhiannon Davies and Kayleigh Griffiths faced in Shrewsbury for years to uncover 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. It took years out of their lives, and that should be deeply respected. It shouldn’t happen.

“These women and their families were disappointed by the shocking level of maternity care with devastating consequences. Adding to the list of mistakes over many years, the voices of victims and the families were never heard, even blamed for the results. That is disgraceful.”

Behrens added: “This report should be a wake-up call for maternity care services and trusts. I agree with Donna Ockenden’s view that maternity care should be properly funded, staff should be properly trained and that when things go wrong, trusts should listen to those affected and learn from their mistakes.”

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