That is an interesting suggestion. We are considering another suggestion in the context of another report we produced concurrently with the people’s ombudsman service report, called, “More complaints please!” That is about changing the atmosphere in our public services, across the public sector, including the health service, so that it is regarded as good to complain  and that complaints are regarded as a good source of information. Every private business knows that a customer who is complaining is giving the business useful information to enable it to improve its service.

We want that kind of atmosphere, but in conversations in the Department of Health, with clinicians and with hospital boards, we find not that there is a lack of avenues to complain through, though the complexity and the maze of complaints channels is dispiriting for people complaining, but that there is no capacity to establish on the ground what exactly has gone wrong and establish the facts of the case soon after the event has occurred. As in the Sam Morrish case, and other cases, there are often arguments about what constitutes legitimate evidence in the complaint. The ombudsman service we have today is not set up to run on-the-ground interviews and post-event investigations. It tends to look at the evidence that it is given. It tends to take the medical records as the medical records. It does not investigate a clinical incident in the manner in which an air accident, for example, would be investigated by experts on the ground immediately after the event. The ombudsman is not there immediately after the event, because the complaint does not get to them until weeks, months or possibly years later. Therefore, we are now conducting an inquiry into NHS complaints and clinical incident investigation.

We do need more capacity. We have a paper in front of us by Carl Macrae and Charles Vincent, which was written up in the Journal of the Royal Society of Medicine in October last year, which suggests that the Department of Health should have a new capacity, much like that of the air accident investigation branch of the Department for Transport, that could go in and establish the facts of the case without fear or favour and without the allocation of blame. There would therefore be much quicker understanding of what has gone wrong and quicker guidance and learning to be spread across the health service.

We will take evidence on that before our seminar next week and we will continue to take evidence until the end of February. We hope to have a report to present to Parliament before the House rises.

I say to my hon. Friend the Member for Brigg and Goole that these are the kind of reforms that we need to consider. We need to remember that the parliamentary and health service ombudsman should be the last resort, not the first port of call, for such complaints. When everything else has failed, it should pick up the hardest cases. There is a dangerous expectation that it is the NHS’s complaints system, but it cannot be, it was not intended to be and Parliament does not want it to be. We want a much better, more agile complaints system in the NHS than we have at the moment. I am pleased that, with the Secretary of State and shadow Secretary of State, we are all at one on this. I hope that all parties will give a fair wind to our inquiry.