Welcome to the third edition of Prioritising patient safety, our quarterly blog series.
Each month, we publish between 70 to 100 of our casework decisions as a way to share learning that will help organisations improve their service and prevent mistakes happening again. In this blog, we explore how findings from our casework can help colleagues across the NHS harness the power of complaints.
In this edition, I will:
- introduce our new Ombudsman, Paula Sussex
- share how we’ve worked together with an NHS Trust to help bring about improvements in organisational culture
- share how one NHS Trust has improved its service following a complaint about sickle cell treatment
- highlight the latest publications in the patient safety space.
A new Ombudsman
On 1 August, Paula Sussex took up her post as new Parliamentary and Health Service Ombudsman. Paula joins PHSO from financial technology firm OneID where she had been CEO since 2023.
Paula has extensive leadership experience in delivering major transformation programmes and services in the public, private and voluntary sectors. She was previously CEO at the Student Loans Company and the Charity Commission.
University Hospitals Birmingham: from concerns to progress
In 2022, we raised serious concerns about University Hospitals Birmingham (UHB) after receiving a number of troubling complaints, some involving potentially avoidable deaths. We were particularly concerned with the Trust’s senior-level response to these cases.
As part of our role in sharing concerns about NHS organisations, we took the unprecedented step of triggering the emerging concerns protocol. This, and other events, led to a series of inquiries into UHB, including one focussed on its leadership culture.
Since then, PHSO have worked with the Trust to support improvements in its leadership and approach to complaints. A new CEO was appointed to UHB following the inquiries. The Ombudsman’s CEO, Rebecca Hilsenrath, recently met with them to discuss progress.
The discussions were encouraging. The Trust’s engagement with PHSO has strengthened and its complaint handling has improved. A significant cultural shift has also taken place.
Responsibility for the Patient Advice and Liaison Service (PALS), complaints and patient experience has moved to the Trust’s Communications Director, who also leads on staff experience. This integrated approach has helped create a more responsive and transparent culture.
The Trust has also invested in data-driven insights to help spot emerging themes early on. A new dashboard, supported by AI, brings together feedback from Care Quality Commission (CQC), PALS, patients, and other sources. Indicators are moving in the right direction, with staff engagement, CQC ratings and complaint turnaround times all improving.
Now, the number of complaints we see about UHB is similar to other large Trusts. The depth of engagement we have with UHB is unusual compared with many other Trusts. We would like to see this level of openness and willingness to improve replicated more widely across the NHS.
Learning from patient experience: sickle cell disorder
Sickle cell disorder is a lifelong condition that mainly affects people from African and Caribbean backgrounds. It causes anaemia and episodes of severe pain, known as sickle cell crises. A sickle cell crisis is when red blood cells change shape, block small blood vessels and reduce blood flow. This requires urgent treatment, often with strong pain relief such as morphine.
Despite national and international awareness initiatives, too often patients report poor experiences of care. One recent complaint we investigated highlights the importance of listening to patients and following agreed care plans.
Ian’s experience
Ian, a paraplegic man living with sickle cell disorder, attended an emergency department in severe pain. He arrived with a pre-agreed care protocol intended to make sure that he received timely treatment. However, his request for urgent attention was not acted upon. He was asked to wait outside in the cold, in significant pain and distress, despite showing staff his protocol multiple times.
It was more than five hours before he got pain relief and he was not admitted to a ward until the following day.
Ian’s complaint highlighted these delays, the failure to follow his protocol, and the distress caused by not being listened to as an expert patient.
The Trust’s response
The Trust engaged positively with our recommendations following Ian’s complaint. They apologised and committed to a number of actions including:
- reminders to triage and navigation teams to prioritise patients in sickle cell crisis
- changes to computer systems to remind junior doctors of the importance of early pain relief
- an annual audit to monitor and improve services.
Ian was also invited to share his story at a Trust-wide learning event so that staff could hear first-hand how delays and failures impact patients. Stories like his help reinforce important lessons and drive cultural and clinical change.
Speak Up Week 2025: Listen, act, build trust
This year, we’ve been invited to support Speak Up Week 2025 which starts on Monday 29 September 2025, led by the National Guardian’s Office. This year’s theme is ‘Listen, Act, Build Trust’. It reflects our own commitment to putting patient and staff voices at the heart of health care improvement.
What’s new in the world of patient safety
Alongside our casework, we continue to contribute to wider patient safety improvements across the NHS:
- the government set out their 10-Year Health Plan for England, which sets out an ambitious direction for care. Commenting on the plan, our CEO Rebecca Hilsenrath said, “The Government’s ambition to put patient experience at the centre of the delivery of care is welcome. Listening to complaints and handling them well is critical to understanding where things are going wrong”.
- Dr Penny Dash’s Review of Patient Safety Across the Health and Care Landscape highlights how recommendations from investigations need to be implemented effectively, an issue we have consistently championed. It builds on work led by the Health Services Safety Investigations Body (HSSIB) nationally, which we have contributed to.
- we also note the important work underway across the patient safety / quality landscape:
- on maternity and neonatal services. HSSIB’s recent review identified systemic issues that need to be addressed nationally. HSSIB has paused its investigation due to the ongoing review led by Baroness Amos. We are also monitoring our complaints related to maternity services.
- An NHS Resolution national webinar, Journey to improvement: engaging patients, families and staff in the improvement of NHS services, is definitely worth tuning in to.
In case you missed it
In the latest episode of our podcast Making Complaints Count we were joined by three guests to explore how the Complaint Standards are helping them learn from feedback to make lasting improvements to their service. We heard from:
- Paul Hetherington, Inclusion and Experience Specialist, Improving Customer Delivery at the Department for Environment, Food and Rural Affairs (Defra)
- Gemma Rauer, Deputy Director of Communications and Engagement and Director of Patient Relations at University Hospitals Birmingham
- Tina Bige, Principal Customer Engagement Manager at Natural England.
Listen to the podcast below to hear more about how they’re using the Complaint Standards to make a positive difference for their colleagues and for people who use their service.