The Parliamentary and Health Service Ombudsman (PHSO) makes final decisions on complaints that have not been resolved by the NHS in England and UK government departments and other UK public organisations.
In our 2018-21 strategy we committed to publishing more information about the outcomes of our casework, including the recommendations we make and what organisations have done to comply with our recommendations.
Publishing more about what we have found will help public services learn from what went wrong and help them to restore trust among patients while ensuring that future patients do not face similar experiences.
We have an important role in sharing the insight from our casework to help others improve public services and complaint handling.
This includes highlighting systemic failings to Parliament if the complaints we have received indicate there is a need for further learning. Such complaints may come from a single NHS trust, as in the case of this report.