The inquiry only came about as a result of a request by Rhiannon Davies, a maternity patient, who is directly affected by the negligent care at a Shrewsbury Hospital.
The detail within the report of the serious level and frequency of medical failure is sadly another example of the NHS not meeting the standards that we should expect of it.
I fear that notwithstanding the public outcry and extensive media coverage over this scandal it will not be the last within the NHS. I remind myself that it follows on from the tragedies at Morecambe Bay and East Kent as well as the Shipman tragic episodes.
Mothers and babies have died needlessly within the Shrewsbury and Telford NHS Trust over decades and yet nobody seemed to want to do anything about it and it was left to a mother tragically losing her new-born baby and not accepting what she had been told to bring about any chance of accountability.
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The problems, albeit specific to Shrewsbury and Telford, are very likely to manifest themselves with other avoidable harm occurring across many of the maternity units in our numerous NHS trusts across the country.
The high level of media coverage of this long-awaited inquiry report has to some degree overshadowed a report released last week which covered the tragedies occurring on a regular basis across our A&E departments up and down the country.
The report into A&E has highlighted 86 deaths plus significant cases of people attending only to suffer serious long-term injury within the hospitals that has had a devastating impact on the lives of the individual and their families.
The rhetoric from Parliament and those public figures making comment who have read the report are clear that lessons will be learned. I am afraid I find this extremely unconvincing.
It was said after all of the above historical scandals that this will be the last of the dying breed of avoidable scandals and yet here we are not only reading a tragic report covering decades of negligent care at Shrewsbury and Telford but also faced with ongoing issues across our A&E departments.
What is not being reported or discussed is the fact that over 40 years ago a national body was set up to record avoidable incidents in the NHS and ensure the NHS learned lessons.