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- Feedback from people who use our service 2023/24 Quarter 1 (April to June)
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- Feedback from people who use our service 2023/24 Quarter 4 (January to March)
- Staff surveys
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- Feedback from people who use our service 2024/25 Quarter 1 (April to June)
- Feedback from people who use our service 2024/25 Quarter 2 (July to September)
- Feedback from people who use our service 2024/25 Quarter 2 (July to September)
- Feedback from people who use our service 2024/25 Quarter 3 (October to December)
- Feedback from people who use our service 2024/25 Quarter 4 (January to March)
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Making a complaint
- Complaints about communication of changes to women’s state pension age
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Handling a complaint
- Complaint Standards
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Conversations that matter most: improving communication in end of life care
- About us
- Foreword from the Ombudsman
- Executive summary
- Introduction
- Communication with the patient
- Case study 1: Failing to inform a patient that his cancer had spread
- Case study 2: Poor communication with a patient about his long-term prognosis and end of life wishes
- Barriers to communicating well with patients: what we heard from clinicians
- Communication with family, friends and carers
- Case study 3: Missed opportunities to keep a family informed about their mother’s condition
- Case study 4: Failing to keep a family updated about their mother’s deteriorating health
- Barriers to communicating well with families: what we heard from clinicians
- Communication between teams and information sharing
- Case study 5: Unclear care plan due to poor communication between specialist teams
- Case study 6: Failing to provide critical information to a care centre about a patient’s condition and needs
- Barriers to communicating well between teams and systems: what we heard from clinicians
- Recommendations
- Foreword
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Podcast
- Archive | Radio Ombudsman podcast
- Bishop Dr Desmond Jaddoo MBE | Making Complaints Count
- Complaint Standards | Making Complaints Count
- Dr Tony Dysart | Making Complaints Count
- Lisa Cowley, CEO at Beacon Vision | Making Complaints Count
- Paula Sussex, Ombudsman
- Rebecca Hilsenrath | Making complaints count
- Sadia Muir, member of our Public Engagement and Advisory Group
- Sandy Lewis, Director of the Maternity and Newborn Safety Investigations Programme
- Complaints to the Ombudsman
- Information for organisations we investigate
- News
- Background to the Warm Front scheme
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Discharge from mental health care: making it safe and patient-centred
- Foreword from the Ombudsman
- Transfers in mental health care: a national picture
- Complaints about discharge and transitions of care in mental health settings
- Case studies: failings in patient, family and carer involvement in discharge planning
- Case studies: poor record-keeping
- Case studies: poor communication between clinical professionals and teams in planning transfers of care
- Recommendations
- Policy and practice: opportunities for change
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Events
- Annual Ombudsman Lecture: Avoiding the Avoidable: Comparative Approaches to Patient Safety
- Barriers to justice and opportunities for PHSO to address them through its new strategy
- Complaint Standards Framework webinar
- Help improve our service: join us at our Dilemma Café
- MP drop-in event: meet the Parliamentary and Health Service Ombudsman
- Meet the Ombudsman: Annual Open Meeting 2019
- Meet the Ombudsman: Annual Opening Meeting 2018
- Information for advocates
- Blog
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End of life care: improving DNACPR conversations for everyone
- Foreword from the Ombudsman
- Executive summary
- Introduction
- Patients and families are not always told about DNACPR decisions
- Conversations often happen too late and in emergency settings
- DNACPR conversations are often left to family members as patient’s wishes have not been discussed before it is too late
- There is a lack of accessible information given at the time or before DNACPR conversations
- There are issues with record-keeping and documenting decisions
- People voiced genuine fears about ageist and ableist attitudes and behaviours in the NHS
- There is a lack of public awareness and knowledge about DNACPR
- Recommendations
- Information for MPs
- Lessons learnt
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Improving ADHD and autism services: commissioning with confidence
- Challenges we see in the system
- Executive summary
- Foreword from the Ombudsman
- Patient case studies
- Poor information and understanding about patient choice affects access to assessment and care
- Recommendations
- The impact of delayed diagnosis
- Variation in quality of assessments driven by gaps in guidance and oversight
- What the system can learn from our complaints and engagement
- The Department’s perspective
- Executive summary
- Foreword and summary
- Press office
- Foreword
- Foreword
- Introduction
- Our strategy 2026 to 2031
- Performance against our Service Charter 2022/23 Quarter 2 (July to September)
- Performance against our Service Charter 2022/23 Quarter 3 (October to December)
- Performance against our Service Charter 2022/23 Quarter 4 (January to March)
- Principles for remedy
- Principles of good complaint handling
- Spotlight on accessible communication: your stories, your rights
- Spotlight on accessible communication: your stories, your rights
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Spotlight on accessible communication: your stories, your rights
- Introduction
- Case summaries: sharing people’s stories
- Trust did not provide BSL interpreters
- Reasonable adjustments not put in place for dyslexia
- HMRC did not consider reasonable adjustments
- Deaf patient not aware of what they were consenting to
- Lack of accessible information for patient with visual impairment
- Making a complaint
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Spotlight on sepsis: your stories, your rights
- Foreword from the Ombudsman
- Introduction
- Delay in diagnosing and treating sepsis after a procedure
- 48-hour delay in diagnosing and treating signs of sepsis
- Failure to treat sepsis before and after a fall in hospital
- Sepsis caused by an untreated pressure sore
- Sepsis caused by poor discharge and lack of follow-up
- Making a complaint about sepsis to the NHS in England
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Spotlight on the Windrush Compensation Scheme: your stories, your rights
- Introduction
- Foreword from the Ombudsman
- Guidance and facts not properly considered
- Eligibility for compensation incorrectly advised for years
- Not all evidence considered for a claim
- Unfairness in rules for close family member eligibility
- Wrong decision made even with supporting evidence
- Making a complaint about the Windrush Compensation Scheme
- Spotlight reports
- Principles of Good Administration
- About complaints investigations, serious incidents and patient safety incidents
- An investigation into HS2’s failure to communicate with a family about acquiring their home
- Current midwifery supervision and regulation – the Nursing and Midwifery Council’s role
- Executive summary
- Introduction
- The complaint
- Background
- Broken trust: making patient safety more than just a promise (report)
- Introduction
- What we can learn from other professions – the Professional Standards Authority’s view
- What we found
- About feedback and complaints management within general practice
- Chapter 1: Summary and insight
- Findings
- Introduction
- National picture
- Our cases
- What needs to change?
- Chapter 2
- Conclusions and recommendations
- Headline figures and insight
- Issue one: Patients being discharged before they are clinically ready to leave hospital
- Our evidence
- Recommendations
- 'Where do I go?'
- Annex A: Our approach and the evidence we gathered
- Chapter 3
- Issue two: Patients not being assessed or consulted properly before their discharge
- Overview of findings
- Annex B: The review - summary
- Chapter 4
- General practice complaint handling: our findings and key areas for improvement
- Issue three: Relatives and carers not being told that their loved one has been discharged
- ‘I don’t want to make a fuss and worry what will happen if I do’
- Annex A: The relevant standards
- Annex C: The survey – summary
- Issue four: Patients being discharged with no home-care plan in place or being kept in hospital due to poor co-ordination across services
- The future of general practice complaint handling
- ‘I’m not sure what difference it would make’
- Annex B – Observations on the Child Death Overview Panel Process
- Annex D: The visits – summary
- Conclusion
- You said, we did
- ‘I would need support’
- Annex E: Advisory group - summary
- Concluding remarks and recommendations
- Our conclusions and recommendations
- Performance against our Service Charter 2021/22 Quarter 2 (July to September)
- Acknowledgements
- Performance against our Service Charter 2021/22 Quarter 3 (October to December)
- Performance against our Service Charter 2021/22 Quarter 4 (January to March)
- Performance against our Service Charter 2022/23 Quarter 1 (April to June)
- Spotlight on maternity care: your stories, your rights
- Annex A: The Data Capture Tool
- Annex B: When a patient raises feedback, concerns or a complaint
- UK Central Government Complaint Standards Easy Read
- Annex C - Listen, support, respond: tips for handling complaints and concerns
- UK Central Government Complaint Standards: Analysis of public consultation responses and next steps
- An investigation into the Department for Work and Pensions’ handling of Ms U’s migration to Employment and Support Allowance
- Continuing Healthcare: Getting it right first time
- Equality, Diversity and Inclusion Strategy 2020-2024
- Investigation into UK Visas and Immigration (UKVI) June 2021
- Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments (Executive Summary)
- Performance against our Service Charter 2019/20 Quarter 3 (October to December)
- Performance against our Service Charter 2019/20 Quarter 4 (January to March)
- Performance against our Service Charter 2020/21 Quarter 1 (April to June)
- Performance against our Service Charter 2020/21 Quarter 2 (July to September)
- Performance against our Service Charter 2020/21 Quarter 3 (October to December)
- Performance against our Service Charter 2020/21 Quarter 4 (January to March)
- Performance against our Service Charter 2021/22 Quarter 1 (April to June)
- Women’s State Pension age: our findings on the Department for Work and Pensions’ communication of changes
- Performance against our Service Charter 2018/19 Quarter 4 (January to March)
- Performance against our Service Charter 2019/20 Quarter 1 (April to June)
- Performance against our Service Charter 2019/20 Quarter 2 (July to September)
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Clinical Advice Review: Final report and our response
- Foreword
- The Clinical Advice Review
- Greater integration of clinical advisers into the casework process
- Effective and consistent communication with all those involved in a complaint
- Balancing evidence and ensuring everyone understands how we use it to reach decisions
- Applying the appropriate range of methods when investigating the causes of poor care, and sharing learning
- Staffing
- Performance against our Service Charter 2018/19 Quarter 3 (October to December)
- Ignoring the alarms: How NHS eating disorder services are failing patients
- Performance against our Service Charter 2017/18 Quarter 2 (July to September 2017)
- Performance against our Service Charter 2017/18 Quarter 3 (October to December)
- Performance against our Service Charter 2018/19 Quarter 1 (April to June)
- Performance against our Service Charter 2018/19 Quarter 2 (July to September)
- Performance against our Service Charter 2017/18 Quarter 1 (April to June)
- Performance against our Service Charter from January to March 2017 (Quarter 4 2016-17)
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Driven to despair
- Foreword
- Executive summary
- The complaints that we have investigated
- Our approach
- The relevant standards
- Roles and responsibilities in fitness to drive decisions
- Our findings
- Comments from DVLA and the Department for Transport
- Recommendations
- Questions for Parliament
- Annex A: The Canadian Risk of Harm Formula
- Annex B: Honorary Medical Advisory Panels Term of Reference
- Decisions and data
- Complaints about the NHS in England
- Complaints about UK government services
- How we deal with complaints
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How we have helped others
- Afghan family reunited after complaint about Passport Office resolved
- Ex-pat left £3,000 a year worse off after DWP took eight years to tell him about pension change
- Father discovered diagnosis by accident
- Helping people use our service
- Teenager left to interpret news that their grandfather might die
- Windrush family wrongly denied pension compensation
- Woman waited eight years for dental treatment after falling through the gaps
- Ambulance delay added to distress after home birth complications
- Contact the team
- Avoidable death of woman after delayed diagnosis and poor management of sepsis
- Avoidable death of woman after multiple failings following routine hip operation
- Avoidable death of woman after nine month delay in cancer diagnosis
- Avoidable eye removal surgery after failure to treat infection
- Our role and relationship with Parliament
- Baby’s death from heart defect was avoidable
- Boy’s life put at risk after Trust withdrew specialist care against wishes of family
- British Embassy failed to support and protect a person detained overseas
- Child Support Agency failed to ensure a parent got £10,000 in child support arrears
- Communication of changes to inflation of state pensions
- Delay in returning passport meant missed holiday
- Delayed diagnosis of HIV resulted in pneumonia and increased risk of other illnesses
- Delays in prostate cancer treatment resulted in decreased quality of life
- Doctors took skin graft from inappropriate place and without telling the patient
- Elderly man with Alzheimer’s died after being left without a carer overnight
- Failure to carry out echocardiogram led to missed opportunity to provide relevant treatment
- Failure to react to signs of sepsis meant opportunity to save life was missed
- Failures in communication caused lost income for sea bass fishers
- Family of murder victim failed by probation provider
- Family paid over £250,000 for care that should have been covered by the NHS
- Family suffered prolonged nuisance and stress after Environment Agency failed to take enforcement action against landfill site
- GP Practice wrongly removed patient and family from their list
- Home Office wrongly tried to remove Windrush generation grandfather
- Man died after excessive wait for cancer treatment
- Man died after medical staff missed opportunities to identify abnormalities on abdominal x-ray
- Man in debt after Jobcentre Plus failed to tell him benefit rules
- Man not told lung cancer was terminal
- Man’s death from perforated bowel was avoidable
- Misunderstanding of patient choice legislation led to delay in diagnosing and treating PTSD
- Motorcyclist wrongly denied the right driving licence
- Ofgem reviewed its earlier decision to claim back £20,000 after a mistake in paperwork by renewable heat supplier
- Poor communication and delays left people not knowing whether they could drive
- Poor record keeping and supervision of staff left a family with significant emotional impact and uncertainty around decisions made about a child’s care
- Surgical error caused unnecessary pain, scarring and avoidable second surgery
- Trust caused pain and fever by prescribing HIV treatment without testing for sensitivity
- Trust did not fully assess man’s suitability to donate kidney to wife
- Trust failed to offer combined chemotherapy, resulting in distress and need to travel long distance for treatment
- Trust failed to treat the mental health of a young person with autism
- Trust missed insulin dose, leading to diabetic ketoacidosis and heart attack
- Trust missed two opportunities to diagnose cervical cancer, leading to an unnecessary hysterectomy
- Trust prescribed wrong anti-psychotic medication, resulting in significant impact on mental health
- UKVI wrongly rejected a visa application for a child, causing three years of distress and uncertainty
- Windrush applicant waited over a year to be rejected
- Woman missed out on benefits because of DWP error and denied compensation
- Woman’s death at mental health hospital was avoidable