Recommendation 15

The PHSO should clarify how the Clinical Advice Quality Framework will improve trust and confidence in the quality and standards of the PHSO’s casework, what changes Parliamentary and Health Service Ombudsman Scrutiny 2021–22 37 have been made to date, and how success will be measured. Furthermore, whilst we acknowledge the challenges associated with the outstanding recommendations from the Donaldson Review, the PHSO should reach a decision as soon as possible on whether to take forward naming clinical advisers in decision reports and sharing provisional reports with advisers, given the review was published four years ago.