It is now more than four years since publication of the Francis Report into the Stafford Hospital scandal, which found that in the years leading up to 2008 hundreds of people died at Stafford Hospital amid “appalling” levels of care.

One of the key findings of Robert Francis, who led the public inquiry, was that the hospital’s board of management had refused to listen to the complaints of patients and staff. It is therefore all the more tragic that despite the clear message from that very expensive and exhaustive inquiry, the NHS continues to fail to learn lessons from even the grossest mistakes.

The Shrewsbury and Telford Hospital NHS Trust delivers about 4,700 babies each year. Despite the fact that its maternity services were severely criticised following the death of a child in 2009, an NHS commission found that there was a “lack of safety culture” at the trust, that the trust had failed to hold staff accountable in relation to the baby’s death and lessons had not been learned. Amid that failing culture it is all the more tragic that other babies died as a result of similar failings.

Hugh James represents families who have suffered similar tragic losses as a result of avoidable mistakes. One constant theme from clients is that they want to be assured that in raising their concerns someone will learn from the error and the same thing will not happen to another patient.

In Wales the Public Services Ombudsman, Nick Bennett, has highlighted the need to embrace complaints and to ensure that a complaints culture exists within NHS organisations. Recent reports on handling of NHS complaints in Wales show delays and, in some cases, a lack of respect for the patients expressing their concerns.

Sadly the cluster of baby deaths at Shrewsbury and Telford NHS Trust do not appear to have been properly investigated and opportunities have been missed leading to no less than seven avoidable deaths.

Whilst recognising that the NHS delivers an excellent service in many areas, and in the face of a significant challenge in terms of resource, nevertheless where the failings do occur it is vital that the NHS looks at the failings, learns from them, and delivers an ever more improved service as a result.