Source · Ombudsmen & enforcement

PHSO Systemic Investigations

4,426 casework decisions 82 systemic investigations 22 recommendations updated to 17 Aug 2026

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.

Systemic investigation reports

Rare, Parliament-facing reports · published occasionally · showing 7 of 82

Report by the Health Service Ombudsman for England of an investigation into a complaint made by Mr and Mrs M

Published 20 May 2013 Systemic Investigation 0 recommendations indexed

This report is about a young woman with physical and learning disabilities who sadly died in January 2009.

The NHS hospital complaints system: A case for urgent treatment?

Published 29 April 2013 Systemic Investigation 0 recommendations indexed

The NHS provides a great service for thousands of people every day. But sometimes things go wrong. When this happens, how people and organisations deal with it determines whether confidence and trust in the service has been restored.

Responsive and Accountable? The Ombudsman’s review of complaint handling by government departments and public organisations 2011-12

Published 11 December 2012 Systemic Investigation 0 recommendations indexed

This report looks at the way government departments and agencies manage complaints. It tells a series of short stories about individuals who, when things went wrong, struggled to get themselves heard.

Listening and learning: The Ombudsman’s review of complaint handling by the NHS in England 2011-12

Published 8 November 2012 Systemic Investigation 0 recommendations indexed

Good complaint handling means listening to patients. Doing so will help deliver the high-quality, patient-centred care that the NHS is committed to. In this report we highlight some of the ways we will be working with the NHS to help achieve this.

Responsive and accountable? The Ombudsman’s review of complaint handling by government departments and public organisations 2010-11

Published 28 October 2011 Systemic Investigation 0 recommendations indexed

This report looks at the way government departments and agencies manage complaints

Listening and learning: The Ombudsman’s review of complaint handling by the NHS in England 2010-11

Published 18 October 2011 Systemic Investigation 0 recommendations indexed

Listening to patients is the key to good complaint handling. Doing so will help deliver the high-quality, patient-centred care that the NHS is committed to. This report highlights some of the ways we will be working with the NHS to help achieve this.

Care and compassion

Published 14 February 2011 Systemic Investigation 0 recommendations indexed

This is a report of ten investigations into complaints made to us about the standard of care provided to older people by the NHS