Published systemic investigation reports from the Parliamentary and Health Service Ombudsman. Browse recommendations, the responses recorded and follow-up evidence. Individual casework decisions are available in a separate register.
In this report, we look at the complaints people have brought to us about ADHD and autism services, to understand what is going wrong and why. We share case summaries showing the impact these problems have had on people's lives, and set out what needs …
In this report, we look at some of the accessible communication complaints people have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. We share case summaries and guidance to help people complain.
Good end of life care depends on good communication. In this report, we draw on the experiences of families and clinicians to set out where communication most often falls short and what needs to change.
This short paper shares insights from senior leaders at NHS trusts across England on how they handle complaints, what complaints reveal and how they use that learning to make improvements.
Our new report spotlights some of the common reasons people were wrongly denied compensation by the Windrush Compensation Scheme.
Investigation into DWP's communication of state pension age changes to women born in the 1950s. Found maladministration in a 28-month delay in writing to affected women. Laid before Parliament under s10(3) because PHSO anticipated DWP would not comply. Government rejected compensation recommendations twice (Dec 2024, …
We are calling for urgent improvements to the process and communication surrounding do not attempt cardiopulmonary resuscitation (DNACPR), so doctors, patients, and their loved ones can make informed choices about their care.
Systemic investigation into unsafe discharge from mental health settings. Based on PHSO casework showing patients being discharged without adequate follow-up, safety planning or family involvement. Makes 5 recommendations covering statutory guidance implementation, 72-hour follow-up extension, nominated person involvement, and the Mental Health Bill.
We've looked at some of the sepsis complaints people have brought to us, to shine a light on their experiences and encourage others to let their voices be heard.
Systemic investigation into patient safety failings across the NHS, examining how the patient safety system fails to learn from mistakes. Draws on PHSO casework to identify failures in local investigations, duty of candour, patient advocacy, and oversight. Makes 7 recommendations to DHSC, NHS England, ICBs …
Following the release of the NHS Complaint Standards in early 2021, we ran a pilot with several NHS organisations between 2021-22 to develop supporting materials, training and guidance that would help the NHS to embed the Standards in its work.
In this report, we look at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard.
Our investigation into how the Hounslow Clinical Commissioning Group (CCG) processed the CHC funding and Personal Health Budget (PHB) for his father, Mr Q. He complained that the CCG did not provide the correct level of care to meet Mr Q’s assessed needs.
This investigation report sets out how the Environment Agency (the Agency) made mistakes in the way it handled an application to harness a renewable energy source. It then refused to fix these errors, causing years of suffering for the Earl family.
The new UK Central Government Complaint Standards will help make the complaints process quicker and easier. The Standards will also help organisations learn from complaints so they can make lasting improvements to services.
Ideas about the rules government organisations should follow when they look at a complaint.
Ms U complained that the Department for Work and Pensions (DWP) failed to pay her Employment and Support Allowance benefits payments over a five-year period due to an administrative error.
Mr N complains about the care and treatment provided to his eight-week-old son who died at University Hospitals Bristol and Weston NHS Foundation Trust.
The data published here includes data about the complaints PHSO received and the decisions made on complaints about the NHS in England and UK Government Departments and other public services in 2019-2020 and 2020-2021.
Our report highlights failings in the way the Department for Work and Pensions (DWP) communicated changes to women’s State Pension age.
This report highlights recurrent failings in the way X-rays and scans are reported on and followed up across NHS services. It recommends a system-wide programme of improvements.
Ms V complained that Immigration Enforcement and UK Visas and Immigration (UKVI) wrongly classed her late father as having no status in the UK when he had indefinite leave to remain. We upheld Ms V's complaint and made recommendations to put things right.
This investigation report found that HS2 failed to properly engage and communicate with a complainant over the sale of their family home to make way for the trainline.
This report highlights the learning from a sample of 60 cases. Ten of these cases are included as case study examples. These cases reveal important learning about the way CCGs have been applying national guidance about NHS CHC.
Mr X complains the Practice were poor at record keeping and failed to pass on information about his father's lack of mental capacity to the …
Mr A complains about a lack of dental interventions over several years. He also complains the Practice did not offer appropriate referrals and removed him …
Mr D complains that the provider reduced his medication without communicating this with him.
Mr C complains HMCTS will not cancel a County Court Judgement (CCJ) registered to his old address.
Mr E complains about the care and treatment his son, received from the Trust between July and August 2023. Mr E complains the Trust discharged …
| # | Body | Investigations |
|---|---|---|
| 1 | Department for Work and Pensions | 4 |
| 2 | HM Government | 3 |
| 3 | Department of Health and Social Care / NHS England | 3 |
| 4 | Department of Health and Social Care | 2 |
| 5 | NHS England | 2 |
1 Section 10(3) report — these rare reports are laid before Parliament when organisations refuse to comply with PHSO recommendations.
Published PDF reports downloaded from ombudsman.org.uk. Full text extracted and stored.
Body name in the report matched to canonical body registry using alias resolution and fuzzy matching.
Recommendation text classified against clinical and administrative themes using AI classification with human spot-checks.
Acceptance status, compliance status and follow-up recommendations extracted and stored against the body record.