Improving frontline complaint handling
In October, we published the UK Central Government Complaint Standards, developed in collaboration with central Government departments, other public bodies, and advice and advocacy groups. Organisations including the Cabinet Office, Department for Transport, HMRC and the Food Standards agency are acting as trailblazers. They will lead the way in embedding the Standards in their organisation and will work with us to further develop and share good practice across the Government.
We received overwhelmingly positive feedback from the NHS Complaint Standards pilot. NHS staff told us the support on offer will make a real, practical difference to complaint handling for them and for service users. We refined, improved and updated the Standards and guidance based on their feedback. In 2023, we will continue working with the NHS in England to embed the Standards into working practices across the NHS.
“The training from PHSO was great and staff really wanted to follow the Standards.” – A mental health organisation
Holding organisations to account
After having concerns about the culture at University Hospitals Birmingham NHS Foundation Trust and the effect on safety for patients and staff, we triggered the Emerging Concerns Protocol in August. This is a process for health and social care regulators to share information that may indicate risks to people using health services. This was the first time the Ombudsman had triggered this protocol, highlighting the degree of concern about its leadership’s response to patient safety incidents and its refusal to accept accountability or learn from past failings.
The action we took generated significant national media coverage and contributed to the establishment of three reviews into the Trust. We wrote to NHS England on 7 March to highlight ongoing concerns and to seek answers why partner organisations were being excluded from contributing to these reviews.
Investigation into Continuing Healthcare funding
We investigated Hounslow Clinical Commissioning Group (CCG) and found a man with complex care needs was put at risk after it failed to properly assess and provide for his healthcare. A live-in carer was also significantly underpaid.
The live-in carer worked alone during nights when two carers were needed, and consistently worked for more than ten hours daily, for many years, to cover gaps in care provision.
The CCG failed to provide necessary funding for round-the-clock support for the patient and did not provide annual increases to fund the carer’s pay. We recommended it pay the former live-in carer £250,000 to put this right.
This came two years after our landmark report outlining common failings seen in NHS Continuing Healthcare, which often resulted in families funding care when the NHS should have done so.
Investigation into women’s State Pension age changes
The investigation into the Department for Work and Pensions’ (DWP) communication of women’s State Pension age changes continued this year, with Stage 2 looking at National Insurance qualifying years, complaint handling by DWP and the Independent Case Examiner, and injustice. The final stage, Stage 3, considers remedy. With a legal challenge brought against us, we have agreed to look again at part of the Stage 2 report, subject to the Court’s approval. The final publication of all three stages will be delayed while this takes place.
We are confident that we have completed a fair and impartial investigation, and we hope this cooperative approach will provide the quickest route to remedy for those affected and reduce the delay to the publication of the final report.
Informing public safety debates
After contributing to the Ockenden and Kirkup investigations, which found avoidable deaths caused by maternity service failings, we published ‘Spotlight on maternity care: your stories, your rights’. This was the first in a new series that aims to share casework insights to add to the evidence and debate on important issues and encourage more people to complain when something goes wrong. Using the stories of people we have supported, it focused on common failings in maternity services, which include communication, diagnosis, aftercare and mental health support. The report gives advice to new and expectant mothers on how to navigate the complaints system and how we can help them access justice.
At the heart of everything we do is creating better services for the public. We worked jointly with the Local Government and Social Care Ombudsman on guidance to tackle common mistakes in mental health in-patient aftercare. Through a series of case studies, the guidance draws attention to recurring mistakes uncovered in the joint investigation work of PHSO and LGSCO when there are misunderstandings between a council and CCG about their collective responsibilities.
Protecting people and improving services
This year, we made 1,013 recommendations to improve services, prevent repeated failings and compensate service users. These case summaries show the range of organisations and complaints we investigate, the significant impact of public service failings on individuals’ lives, and how we make a real difference to people who have faced inustice: