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What we can and can't help with
- Complaints about communication of changes to women’s state pension age
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How we have helped others
- Afghan family reunited after complaint about Passport Office resolved
- Ambulance delay added to distress after home birth complications
- 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
- 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 lost chance for potentially life-saving treatment after hospital failed to diagnose cancer
- 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
- Complain to us: getting started
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For organisations we investigate
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Complaint Standards
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NHS Complaint Standards
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Good complaint handling guides
- A closer look: providing a remedy
- Capturing and reporting on learning from complaints
- Carrying out the investigation
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- Step-by-step guide: writing the final response letter
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- Writing and communicating your final response
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NHS Complaint Standards toolkit
- Advocacy, advice and support: When to refer and who to
- Independent advocacy reference table
- NHS Complaint Standards Sample Letters
- NHS Complaint Standards sample copy
- NHS Complaint Standards sample forms
- NHS Complaint Standards sample letters
- NHS Complaint Standards sample posters
- NHS Complaint Standards: step-by-step guides
- Organisational assessment tool for the NHS
- Tips to improve GP complaint handling
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Good practice in complaint handling
- A 'Complaints Panel' to put complaints at the heart of governance
- A new Complaint Standards Authority: How using a single set of standards has improved efficiency in the Scottish public sector
- Engaging online: How embracing patient feedback is helping to make improvements in patient care
- How early, direct engagement improved the experience of staff and complainants
- It’s good to talk: How taking a proactive approach to patient engagement has helped resolve concerns in real time and improve services
- Understanding complaints: How Mersey Care adopted a just and learning culture
- Promoting a just culture
- Responsibilities of the lead organisation: step-by-step guide
- Using the NHS Complaint Standards and supporting guidance
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Complaint Standards for the NHS
- Why we need the Complaint Standards
- Benefits of the Complaint Standards
- Complaint Standards at a glance
- Promoting a just and learning culture
- Welcoming complaints in a positive way
- Giving fair and accountable responses
- Being thorough and fair
- Other NHS complaint handling requirements
- Complaint Standards: Partner organisations
- Definitions
- Model complaint handling procedure for NHS Services in England
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Good complaint handling guides
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UK Central Government Complaint Standards
- Help, support and advice for people who complain
- Holding an initial discussion
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UK Central Government Complaint Standards
- Foreword from Rob Behrens
- Definitions
- About the UK Central Government Complaint Standards
- Why we need the Complaint Standards
- Complaint Standards at a glance
- Promoting a learning culture
- Welcoming complaints in a positive way
- Being thorough and fair
- Giving fair and accountable responses
- Other central government complaint handling requirements
- Working in partnership to build the UKCG Complaint Standards
- UK Central Government Complaint Standards: Model complaint handling procedure
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UK Central Government good complaint handling guides
- Capturing and reporting on learning from complaints
- Managing challenging situations in complaint handling
- The role of parent departments: overseeing complaint handling
- Carrying out the investigation
- Clarifying the complaint
- Complaints about multiple organisations
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- Early resolution: resolving complaints quickly
- Identifying a complaint
- Making sure people know how to complain
- Providing a remedy
- Referring service users to the Ombudsman
- Who can make a complaint and what consent do you need
- Writing and communicating your final response
- UKCG Complaint Standards: Organisational assessment tool
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- Using the Complaint Standards and supporting guidance
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NHS Complaint Standards
- Complaints and fitness to practice procedures, legal action and other procedures
- Good leadership and complaints
- What happens if someone complains about your organisation
- Putting things right
- Support and advice
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What our data tells us
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Quarterly reports on complaints about NHS trusts
- Complaints about acute Trusts
- Complaints about acute trusts April to September 2016
- Complaints about acute trusts January to March 2016
- Complaints about acute trusts July to September 2015
- Complaints about acute trusts April to June 2015
- Complaints about health organisations for the year 2014-15
- Complaints about acute trusts 2013-14 and April to September 2014-15
- What people think of complaining
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Quarterly reports on complaints about NHS trusts
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Complaint Standards
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About us
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Who we are
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The Board
- Audit and Risk Assurance Committee
- Governance statement
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Members of the Board
- Anu Singh Non-executive
- Balram Gidoomal CBE, Non-executive
- Dean Fathers, Non-executive
- Deputy Ombudsman
- Dr Julia Tabreham, Non-executive
- Executive Chair
- Gill Kilpatrick, Chief Executive
- Helen Walley, Non-executive
- Linda Farrant Non-executive
- Non-executive Board member
- Non-executive Board member
- Non-executive Board member
- Non-executive Board member
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- Non-executive
- Rebecca Hilsenrath, Ombudsman
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- Sir Alex Allan, Non-executive
- Sir Jon Shortridge, KCB, Non-executive
- The Ombudsman
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Corporate information
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How we are performing
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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 3 (October to December)
- Feedback from people who use our service 2023/24 Quarter 4 (January to March)
- Feedback from people who use our service 2024/25 Quarter 1 (April to June)
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Performance statistics
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- July to September 2022 performance statistics
- October to December 2020 performance statistics
- October to December 2021 performance statistics
- October to December 2022 performance statistics
- Quality Standards results 2021/22 Quarter 1 (April to June)
- Quality Standards results 2021/22 Quarter 1 (July to September)
- Quality Standards results 2021/22 Quarter 3 (October to December)
- Quality Standards results 2021/22 Quarter 4 (January to March 2022)
- April to June 2017 performance statistics
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- October 2014 performance statistics
- October 2015 performance statistics
- October 2016 performance statistics
- September 2014 performance statistics
- September 2015 performance statistics
- September 2016 performance statistics
- Freedom of information and data protection
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How we are performing
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News and blog
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Podcast
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Archive | Radio Ombudsman podcast
- Polly Curtis on the relationship between state and citizens
- Radio Ombudsman #22: Baroness Hale of Richmond on blazing a trail and balancing objectivity with empathy in the courtroom
- Radio Ombudsman #24: Derek Richford on how personal tragedy led to uncovering a maternity scandal
- Transcript of Radio Ombudsman #10: Jenna Brown on being an Ombuds across borders
- Transcript of Radio Ombudsman #11: Marie Anderson on the case for own-initiative powers
- Transcript of Radio Ombudsman #12: Rachel Power, CEO of the Patients Association, on putting patients at the heart of NHS care
- Transcript of Radio Ombudsman #13: Rosemary Agnew on the benefits of being a Complaints Standards Authority
- Transcript of Radio Ombudsman #17: Catalan Ombudsman Rafael Ribó on championing human rights
- Transcript of Radio Ombudsman #18: Ian Trenholm on integrity, curiosity and effective regulation
- Transcript of Radio Ombudsman #19: Sir Robert Francis on why listening to patients is vital to improve services
- Transcript of Radio Ombudsman #1: How can the NHS and the PHSO get better at learning from mistakes?
- Transcript of Radio Ombudsman #21: Lord Victor Adebowale on reshaping post-COVID NHS health and care systems
- Transcript of Radio Ombudsman #23: Day Riley on being transgender, mental health and what Pride means to her
- Transcript of Radio Ombudsman #25: Will Powell on the tragic loss of his son and his 30-year quest for justice
- Transcript of Radio Ombudsman #26: Angela MacDonald on her role as Complaints Champion for UK Government
- Transcript of Radio Ombudsman #2: The challenges of being an Ombudsman - operations, policy and refom
- Transcript of Radio Ombudsman #32: Dr Sooj on making health advice go viral and battling misinformation
- Transcript of Radio Ombudsman #33: Rob Behrens on his life and career as the Ombudsman
- Transcript of Radio Ombudsman #3: Approaches to mediation and dispute resolution
- Transcript of Radio Ombudsman #6: Making the NHS safer for patients
- Transcript of Radio Ombudsman #7: driving improvements in mental healthcare
- Transcript of Radio Ombudsman #9: Avoiding the avoidable to improve the safety of NHS care
- Transcript of Radio Ombudsman podcast #4: Sir David Behan on the transformation of the Care Quality Commission
- Transcript of Radio Ombudsman podcast #5: In conversation with European Ombudsman, Emily O'Reilly
- Bishop Dr Desmond Jaddoo MBE | Making Complaints Count
- Rebecca Hilsenrath | Making complaints count
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Archive | Radio Ombudsman podcast
- News
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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
- Working seminar on the Manchester Memorandum 2021
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Podcast
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Publications
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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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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
- 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)
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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
- An investigation into HS2’s failure to communicate with a family about acquiring their home
- Broken trust: making patient safety more than just a promise (report)
- Performance against our Service Charter 2021/22 Quarter 2 (July to September)
- 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
- UK Central Government Complaint Standards Easy Read
- 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
- Complaints about the NHS in England: Quarter 1 2019-20
- 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)
- The Art of the Ombudsman: leadership through international crisis
- 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)
- The Ombudsman’s Casework Report 2019
- Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust
- Blowing the whistle: an investigation into the Care Quality Commission’s regulation of the Fit and Proper Persons Requirement
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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)
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Complaints about UK government departments and agencies in 2017-18
- The complaints we dealt with
- Why we upheld complaints
- Making changes to our service
- Improving complaint handling and good practice
- HM Courts & Tribunals Service: Improving communication
- HM Revenue and Customs: Gathering insight and acting on feedback
- The Adjudicator’s Office: Supporting HMRC to improve complaint handling
- NHS England: Flexible complaints training for healthcare professionals
- Ignoring the alarms: How NHS eating disorder services are failing patients
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Maintaining momentum: driving improvements in mental health care
- Foreword
- Introduction
- About us
- The state of mental health provision in the 21st century
- How we chose these complaints
- Complaint handling
- The complaints we see: overview
- The complaints we see: diagnosis and failure to treat
- The complaints we see: risk assessment and safety
- The complaints we see: dignity and human rights
- The complaints we see: communication
- The complaints we see: inappropriate discharge and provision of aftercare
- Next steps
- Further resources
- 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 2017/18 Quarter 4 (January to March)
- 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)
- Breaking down the barriers: Older people and complaints about health care
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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
- Dying without dignity
- Learning from mistakes
- Midwifery supervision and regulation: recommendations for change
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An opportunity to improve
- Foreword
- Executive summary
- Introduction
- About feedback and complaints management within general practice
- Our approach
- Overview of findings
- General practice complaint handling: our findings and key areas for improvement
- The future of general practice complaint handling
- You said, we did
- Concluding remarks and recommendations
- Acknowledgements
- Annex A: The Data Capture Tool
- Annex B: When a patient raises feedback, concerns or a complaint
- Annex C - Listen, support, respond: tips for handling complaints and concerns
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A report of investigations into unsafe discharge from hospital
- Foreword
- Introduction
- Issue one: Patients being discharged before they are clinically ready to leave hospital
- Issue two: Patients not being assessed or consulted properly before their discharge
- Issue three: Relatives and carers not being told that their loved one has been discharged
- Issue four: Patients being discharged with no home-care plan in place or being kept in hospital due to poor co-ordination across services
- Conclusion
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A review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged
- Introduction
- About complaints investigations, serious incidents and patient safety incidents
- What we found
- What needs to change?
- Headline figures and insight
- Annex A: Our approach and the evidence we gathered
- Annex B: The review - summary
- Annex C: The survey – summary
- Annex D: The visits – summary
- Annex E: Advisory group - summary
- Time to Act
- Warm Front: how early engagement with the Ombudsman helps to resolve complaints
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Discharge from mental health care: making it safe and patient-centred
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