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Maintaining momentum: driving improvements in mental health care

About us

The Parliamentary and Health Service Ombudsman was set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments.

Our investigations look at the difference between what happened and what should have happened. If we find something went wrong we will make recommendations to put things right, both for the people directly affected and to ensure the service improves to prevent the same mistakes happening again.

We make recommendations to put things right for the individual, taking account of the scale of the injustice and what the individual wants. These remedies can include acknowledging and apologising for mistakes.

We also aim to put the complainant in the position they would have been in had the mistakes not happened. This can be difficult and in some cases we recommend that a financial payment should be made to achieve this, although complainants often do not want a payment and we will take this into consideration.

We also ask organisations to show how they will prevent the same mistakes happening again. In all the complaints included in this report, we recommended the organisation produce an action plan to make changes. This was to ensure the organisation learned from the complaint by looking again at what went wrong and actively identifying how they could improve their service.

We have produced guidance for how organisations can produce an action plan. We also ask them to share their action plans with the CQC to inform their inspections and, where relevant, NHS Improvement, which works with NHS trusts to help improve their services.

We will shortly be publishing our own new three-year strategy, in which we will commit 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.

Meanwhile, we use reports like this to highlight key themes from our casework so that those working in, leading and scrutinising public services can improve.