Mick Martin, Managing Director at Parliamentary and Health Service Ombudsman said:
We welcome the report's recommendations. The proposed review of the NHS complaints system to improve the quality of complaint handling at a local level is a step forward and will help patients and their families get answers they deserve when things go wrong. We've been calling for changes to midwifery supervision and regulation and expect legislation now.
We are finalising our memorandum of understanding with the Care Quality Commission to be clear about roles and responsibilities and how we work together in the interests of patient safety.
As the report states our decision not to investigate was made in good faith and based on evidence at the time. That is not a decision we would make today.
We've been listening and learning from people who use our service and now investigate all complaints concerning allegations of avoidable death.