Improving frontline complaint handling
In April 2023, we rolled out our new Continuing Professional Development (CPD)-accredited training courses to help organisations deliver the NHS Complaint Standards. Since then, we have delivered 743 training sessions to 563 NHS staff from more than 150 different organisations. 97% of attendees said the training helped them to make positive changes to the way they deal with and respond to complaints. These training courses have been in high demand, and we are developing new versions to allow more NHS staff to attend.
“I found the course really helpful. I have already had meetings with my manager regarding changes we need to make, and I have recommended to my colleagues.”
NHS Complaint Standards training course attendee
Following publication of our Complaint Standards for UK central Government, we have worked closely with five trailblazer departments to make sure the Standards work in practice. They have shared their positive experiences of using the Standards materials with us and with Government colleagues at the Cross Government Complaints Forum. We have also worked with our trailblazers to develop versions of our CPD-accredited training for this sector and will roll this out over the next year.
“We have a lot of new staff so have been using the Complaint Standards to support with our formal training and coaching process. This has helped aid consistency in customer responses.”
DVLA
Holding organisations to account: State Pension age investigation
Following a comprehensive investigation that examined thousands of pages of evidence, we published our final report on communication of women’s State Pension age changes by the Department for Work and Pensions (DWP). We found failings in how DWP communicated information about the changes, and the way it investigated and responded to complaints about these issues. We found these failings led to missed opportunities to make informed decisions and caused unnecessary stress, anxiety and confusion.
We had reason to believe DWP would not take steps to put things right, so we presented our report to Parliament so it could intervene and find a way to provide appropriate remedy for the women affected.
Our report dominated the news agenda for the day and our recommendations and findings continue to be debated. There has been a commitment by Government to report back at the earliest available opportunity.
“Complainants should not have to wait and see whether DWP will take action to rectify its failings… Parliament now needs to act swiftly, and make sure a compensation scheme is established.”
Rebecca Hilsenrath as Chief Executive Officer in 2023 to 2024
“We continue to take the work of the Ombudsman very seriously, and it is only right that we now fully and properly consider the findings and details of what is a substantial document. In laying the report before Parliament, the Ombudsman has brought matters to the attention of the House, and we will provide a further update to the House once we have considered the report’s findings.”
Mel Stride, Secretary of State for Work and Pensions
Informing patient safety debates
At the heart of everything we do is creating better services for the public. By publishing our health reports and raising the profile of our investigations into NHS services, we contribute to patient safety debates.
We laid our landmark report ‘Broken trust: making patient safety more than just a promise’ before Parliament in June 2023. The report examines cases we investigated where patients died due to avoidable errors. We said the NHS must do more to accept accountability and learn from mistakes and we set out recommendations to improve patient safety.
“The Ombudsman’s report offers important insights into where the NHS has fallen short, and the progress it still needs to make in how it cares for patients and their families. We agree strongly with the Ombudsman that embedding and supporting patient safety should be a consistent priority for the Government.”
Miriam Deakin, Director of Policy and Strategy, NHS Providers
As a result of our work, the Ombudsman was invited to be part of the discussions with the Department of Health and Social Care in September 2023 on how to introduce ‘Martha’s Rule’. This is a new measure to be adopted by the NHS to support people in raising urgent concerns about treatment, to have round the clock access to critical review teams if they are worried about their own, or a loved one’s, condition.
In the wake of the Lucy Letby trial, we reiterated our recommendations and concerns about a culture of fear and defensiveness in the NHS. The Ombudsman wrote to the Health Secretary calling for the proposed inquiry into these events to have statutory status. The inquiry will now use all legal powers available, including the power to compel witnesses to give evidence, which will help the families get to the truth of what happened.
“The culture of fear and defensiveness within the NHS is not isolated to this [Letby] case, it is a widespread problem which our Broken Trust report laid bare. These recent events mean our recommendations take on even more urgency.”
Sir Rob Behrens as Ombudsman 2023 to 2024
We published ‘Spotlight on sepsis: your stories, your rights’, sharing casework insights ten years on from our ‘Time to Act’ report and encouraging more people to complain when something goes wrong. Using the stories of people we have supported, it focused on common failings, including delays in diagnosing and treating sepsis, poor communication and record-keeping, and a lack of follow-up care.
“With sepsis claiming an estimated 48,000 lives annually in the UK, this report demonstrates that there is an urgent need to establish sepsis as a key priority for healthcare.”
Dr Ron Daniels, Chief Executive Officer of the UK Sepsis Trust
In February 2024, our report on ‘Discharge from mental health care’ analysed complaints where we had found failings in discharge and transition in the care of patients with mental health conditions.
Our recommendations included extending follow-up checks within 72 hours of discharge from inpatient mental health settings to include discharge from emergency departments. Our recommendations are designed to help NHS leaders prioritise the safety of patients with mental health conditions and to hold them accountable for doing so.
“This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.”
Lucy Schonegevel, Director of Policy and Practice at Rethink Mental Illness
After submitting evidence to the COVID-19 Public Inquiry on the impact of the pandemic on the health service, we highlighted themes from our casework in our ‘End-of-life care’ report. This looked at issues that patients, their families and clinicians experienced in the ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) process. These challenges are affecting disabled people and older people in particular.
“We need to be having these discussions earlier as a nation rather than leaving them for an urgent situation. This is where misunderstanding occurs due to high emotions on both sides.”
Doctor working in geriatric medicine