Parliamentary and Health Service Ombudsman
@PHSOmbudsman
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We investigate complaints about the NHS in England, UK government departments and public bodies, including museums. Our service is free, fair and independent.
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Joined September 2011
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Pinned Tweet
We wanted to share some top tips on how to make a complaint to the NHS in England:
- Decide what you hope to achieve
- Make your complaint clear
- Complain as soon as possible
For more top tips, visit our website:
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We've published our report about failings in
@DWP
’s communication of changes to
#StatePensionAge
.
You can read the report on our website:
#50sWomen
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We found failings in the way
@DWP
communicated women’s
#StatePensionAge
changes. We will now consider the impact of these failings and what action should be taken next.
Read our report:
#50sWomen
18
97
143
"Parliament now needs to act swiftly and make sure a compensation scheme is established."
CEO
@RJHilsenrath
comments on our investigation which found DWP failed to adequately communicate changes to women's State Pension age.
Read more:
17
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137
We analysed over 1,000 pages of evidence during our investigation which found failings in the way DWP communicated changes to women's State Pension age.
We're urging Parliament to intervene and identify a way to provide compensation to those affected.
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127
Our report out today highlights that
@DWP
delayed writing to women about changes to the
#StatePensionAge
. It should have written to the women affected at least 28 months earlier than it did.
Read more:
#50sWomen
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121
@justice41960265
We are continuing our investigation into DWP’s communication of changes to women’s state pension age. Please visit our website for further info:
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Defensive NHS culture "leads to a perception that organisational reputation and professional reputation are more important than patient safety."
Ombudsman
@RobBehrens1884
spoke to
@bmj_latest
about why NHS culture change is essential.
Read more:
35
67
111
We have now completed and closed stage two of our investigation into the way the Department for Work and Pensions (DWP) communicated changes to women’s State Pension age.
Visit our website to find out more:
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110
We've published stage two and three of our investigation into complaints about the communication of changes to women's State Pension age.
We are presenting this to Parliament and asking it to intervene and identify a way to provide appropriate remedy.
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"Too many leaders are interested in preserving the reputation of their organisation, rather than listening to citizens."
Ombudsman
@RobBehrens1884
warns that hospitals are covering up serious mistakes in patient care.
Read more in
@thetimes
(paywall):
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We've published an update on our investigation into failings in DWP's communication of changes to
#StatePensionAge
.
Visit our website to find out more:
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Today we’re presenting the findings from our new report 'Broken trust: making patient safety more than a promise'.
The report examines cases where patients died due to avoidable errors & sets out how we can
#PatientSafety
more than just a promise.
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53
66
"Listening when things go wrong is the very least patients should expect."
In our blog for
#WorldPatientSafetyDay
, Director of Strategy
@K_Eisenstein
says safe care needs patient voices, but is the NHS ready to listen?
Read more:
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Following the High Court ruling, we have written to our sample of complainants to see if they are happy with our revised proposal to investigate their
#complaints
about changes to the state
#pension
age for women. Find out more:
#womenspensions
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Update: Complaints about communication of changes to women’s State Pension age.
We have shared our provisional views with complainants, their MPs and the DWP.
We carefully analysed over 650 pieces of evidence to make sure our findings are robust.
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We will now consider the impact of these failings, and what action should be taken to address them.
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20
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Many thanks to
@willcpowell
for coming to talk to us today, sharing a deeply moving account of son Robbie’s avoidable death & his 28-year struggle for the truth. The Ombudsman reiterated his support for a focused inquiry addressing allegations of cover-up & lessons to be learned.
8
35
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Tonight’s
@BBCPanorama
highlights how vital it is for
#NHS
Trusts to be transparent and learn from mistakes. This cannot happen if failings are buried.
#BBCPanorama
#DutyOfCandour
8
22
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#MeetPHSO
@JamesTitcombe
tells delegates: 'We need an NHS
where we don’t blame people for human error but we do act quickly. We need to
separate complaints from serious patient safety incidents, which shouldn’t be
going through the complaints system
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"
#PatientSafety
is not held in as high esteem as the reputation of the trust."
@RobBehrens1884
discusses a report into how a mental health trust mismanaged its mortality figures, which was edited to remove criticism of its leadership.
Watch on Newsnight:
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44
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#WorldPatientSafetyDay
is an opportunity to shine a light on creating a 'learn not blame’ culture as an essential step towards improving
#PatientSafety
. To do this, learning & accountability must go hand-in-hand says
@K_Eisenstein
in our latest blog:
#FTSU
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Women’s State Pension age: our findings on injustice and associated issues discussed on
@BBCRadio4
#AnyQuestions
today.
We’re calling on Parliament to act swiftly to compensate
#50sWomen
affected.
Read more about our investigation:
10
45
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Good to see how
@LGH_SPFT
is empowering patients to lead on their care by calling them service leaders rather than service users. Ward tours at Langley Green Hospital today showed how feedback from service leaders and carers is central to shaping changes in care provision.
8
23
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"We cannot have a situation where people don't want to complain because they don't want to cause trouble."
@RobBehrens1884
talks to
@SkyNews
about the results of our NHS
#MentalHealth
survey.
Read more about the survey:
27
38
49
“Nobody should feel that they're a nuisance for making a complaint.”
Dr Bill Kirkup discusses how the health service should change their approach to handling complaints in the latest Radio Ombudsman podcast.
Listen:
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“The big need is to change the culture from being defensive to majoring on patient safety."
Ombudsman
@RobBehrens1884
spoke to
@GranadaReports
about his letter to the Health Secretary asking for a wider review into the culture and leadership in the NHS.
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We've been working with partners across the health sector to create a single set of standards for the NHS to follow when responding to
#NHSComplaints
.
But what do you think it should it look like? Have your say in the public consultation starting next week!
#MakeComplaintsCount
16
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A seriously ill woman’s complaint has uncovered a DWP error which halved her benefits for five years.
The same error has affected at least 118,000 people with disabilities and health problems.
Read about our investigation:
#DeniedCompensation
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Calling all doctors! 🩺 📢
We're trying to better understand whether the current DNACPR process works, or if changes are needed to help support you during these critical decisions.
Our latest survey invites you to share your experience of DNACPR:
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Four things you can do as a leader to create a culture that values and learns from complaints:
1. Create a culture of
#LearnNotBlame
2. Avoid a concern becoming a complaint
3.
#MakeComplaintsCount
4. See the bigger picture
Find out more:
#FTSU
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Today we begin to routinely publish PHSO casework decisions on our website.
The findings from our investigations will help the
#NHS
and government bodies drive improvements in their services and
#MakeComplaintsCount
.
Read our blog to find out more:
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Ombudsman Rob Behrens visited
@NCAlliance_NHS
Pennine Acute Hospital NHS Trust today and found the leadership of the paediatric ward to be inspirational.
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12
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Our latest report sheds light on people complained to us about the
#sepsis
care they’ve received.
We found that delays, lack of communication and poor follow-up all contributed to failings.
Read more:
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32
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A seriously ill woman’s complaint has uncovered a DWP error which halved her benefits for five years.
The same error has affected at least 118,000 people with disabilities and health problems.
Read about our investigation:
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There were 67,400 severe harm
#PatientSafety
incidents in the
#NHS
in the last year, says
@DonaldsonLiam
at
#LSEPHSO
lecture on ‘Avoiding the avoidable’.
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42
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Ombudsman warns urgent action is needed as lessons ‘not learned’ from
#sepsis
failings.
@RobBehrens1884
told
@itvnews
"the NHS needs to listen to patients and their families when they raise concerns. It needs to be sepsis aware."
Read more:
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The new and improved
#NHSComplaints
Standards are published today.
They set out how NHS organisations should approach complaint handling to
#MakeComplaintsCount
.
Find out more:
9
27
39
Saying sorry meaningfully when things go wrong is the moral and right thing to do. It is vital for everyone involved in an incident, including patients and staff.
@NHSResolution
has helpful guidance on why, when and how to say sorry:
#DutyOfCandour
#NHS
5
19
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Today we publish a report on complaints about NHS Continuing Healthcare. It includes evidence-based recommendations to help the system improve so that people get the care they are entitled to.
Find out more:
#NHSCHC
#ContinuingHealthcare
#CHC
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Throughout the
#LucyLetby
trial we heard that clinicians repeatedly raised concerns and called for action but nobody listened. NHS culture and leadership must improve so staff and patients' voices are heard and acted on, says
@RobBehrens1884
.
Read more:
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Vulnerable people are “losing their
#HumanRights
when put in difficult situations where they had no control".
Ombudsman
@RobBehrens1884
warns that the human rights of
#MentalHealth
patients are being violated amid care crisis.
Read more
@Independent
:
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Ombudsman
@RobBehrens1884
says that government departments are covering up serious wrongdoing and “fobbing off” people who complain about negligence and mistakes in his interview with
@thetimes
Read more:
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The
#NHS
is failing patients with
#MentalHealth
problems. Our
#MaintainingMomentum
report underlines the need for radical improvement & urges leaders to maintain focus on realising the Five Year Forward View:
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More babies face harm unless NHS ends ‘defensive leadership’ says
@RobBehrens1884
in exclusive
@guardian
interview on
#LucyLetby
, as he calls for urgent change in ‘unacceptable’ attitudes to whistleblowing:
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Help shape future NHS complaint handling!
With health sector partners, we've created a single set of standards for responding to
#NHSComplaints
and we'd like to know what you think.
💬 Have your say in the public consultation starting tomorrow (15 July).
#MakeComplaintsCount
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Today we and
@NHSResolution
launch a new guide for
#NHS
staff who manage complaints and/or claims. It explains our roles and how we work together to resolve NHS complaints and compensation claims. Download a pdf (344kb) here:
#ComplaintsHandling
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Ombudsman
@RobBehrens1884
has announced his resignation from the European Ombudsman Institute after it was found that the organisation supported the illegal deportation of Ukrainian children from Austria to Russia.
Read more:
1
15
33
We are delighted to announce our Expert Advisory Panel:
➡️ Dr Bill Kirkup
➡️
@JamesTitcombe
➡️ Suzy Ashworth
➡️ Dr Nick Coleman
The panel will challenge & support our work to make sure we are providing the best possible service. Find out more:
4
20
32
Windrush man wrongly classified as illegal immigrant left destitute for a year.
@ameliagentleman
of
@guardian
reports on our recently published
#Windrush
case that found failings at UK Visas and Immigration:
6
34
30
MPs are currently responding to a statement on the Ombudsman's report on women born in the 1950s who were affected by failings in communication about State Pension age change.
Watch on :
3
22
31
@HilaryWyles
@davidhencke
By law, we investigate in private. We ask people to respect the confidential nature of our work and not to share information while the investigation is ongoing.
2
19
30
🏥
@RobBehrens1884
speaking about our Broken trust report at the
@HSJptsafety
conference today
#HSJPatientSafety
You can read the report on our website:
4
20
31
"Those who lost their children deserve to know... how it was that doctors were not listened to... Good leadership always listens, especially when it’s about patient safety."
@RobBehrens1884
comments on the Lucy Letby verdict :
2
20
31
➡️ NEW survey published today
Our
#MentalHealth
survey found 1 in 5 people did not feel safe while under the care of NHS mental health services in England.
Read the press release:
6
44
29
Our joint letter with
@OmbudsmanWales
clearly sets out the case for a proper public inquiry into the tragic death of Robbie Powell.⬇️
Pls RT
I've received a joint letter from
@RobBehrens1884
&
@OmbudsmanWales
setting out Robbie's extraordinarily strong case & why a public/independent inquiry is justified into the 30yr State cover up!
The letter has been copied to the Chairmen of
@CommonsPACAC
&
@CommonsHealth
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2
24
29
"Eating disorders are urgent problems and unless taken seriously, people do die. But they don't need to. People can get better."
Our CEO
@RJHilsenrath
called for action to end avoidable deaths of people with eating disorders on
@BBCr4Today
.
🎧 from 53m:
3
16
29
Mental health patients are being failed when they leave care, warns Ombudsman.
Our latest report examines how
#MentalHealth
patients are getting stuck in a continuous revolving door of care & discharge, and what needs to be done to stop this.
Read more:
4
25
28
For our next
#RadioOmbuds
podcast we'll be talking to Claire Murdoch, National Director for
#MentalHealth
@NHSEngland
about driving improvements in mental health care to deliver on the Five Year Forward View. If you have questions for Claire, tweet us by 5pm on Friday.
3
25
27
Despite awareness of
#sepsis
increasing over the last ten years, we're still seeing complaints where we find someone has died from sepsis because they did not receive the right care at the right time.
Here's a reminder of what to watch out for from
@UKSepsisTrust
#WorldSepsisDay
3
20
28
This afternoon our CEO
@RJHilsenrath
spoke to
@ChrisMasonBBC
about our investigation which found DWP failed to adequately communicate changes to women's State Pension age.
Tune into BBC News this evening for more.
2
22
27
Today, we've published an investigation that found a six-month-old baby died because his heart defect was not diagnosed and treated, despite multiple opportunities to do so.
#LearningFromDeaths
2
19
26
As 2021 comes to a close, we wanted to share some of the reports we published this year:
- The Art of the Ombudsman:
- Women’s State Pension Age:
- HS2:
- Windrush:
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24
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The NHS must do more to accept accountability and learn from mistakes when there is serious harm or loss of life.
Our latest report sets out what needs to happen to make
#PatientSafety
more than just a promise.
Read more:
17
26
27
Today we are launching our new clinical standard – the Ombudsman’s Clinical Standard. Find out more:
16
36
26
Our latest report examines cases where patients died due to avoidable errors.
We’re calling for urgent action from the Government to make
#PatientSafety
more than just a promise and protect families who’ve suffered tragedies following avoidable deaths.
9
23
27
October is
@NatGuardianFTSU
#SpeakUpMonth
. This is a really important campaign that we're keen to support. We all have a duty to create a more open culture in the health service. Watch Rob Behrens' video message:
9
22
26
Great to take part in the
@OmbudAssoc
seminar today, discussing how best to reach people less likely to complain.
26
16
26
Today we publish a report on complaints about
#NHS
#imaging
.
It includes evidence-led recommendations to help the health system improve so that patients consistently receive high-quality and safe care.
Read it here:
#LearningFromMistakes
4
24
26
"Being shocked is not enough. We have to create a learning culture within the NHS."
Ombudsman
@RobBehrens1884
explained to
@bbcbreakfast
that the lives of cancer patients were being put at risk by an over-stretched health service.
Read more:
5
14
26
#BarredFromJustice
: vulnerable people locked out of
#LegalAid
to challenge unlawful deportation orders, Ombudsman finds.
Read the full story:
@LawCentres
4
23
26
A mother's seven-year fight for justice after her son died under
#MentalHealth
care
@itvnews
. Our report found systemic failure to tackle repeated & critical failings over an unacceptable period of time, &
#MissedOpportunities
to ensure
#PatientSafety
:
2
18
25
The NHS must do more to accept accountability and learn from mistakes when there is serious harm or loss of life.
Our latest report sets out what needs to happen to make
#PatientSafety
more than just a promise.
Read more:
15
13
25
“Too often the wellbeing of women and babies is put at risk by a lack of safe, effective, and compassionate care.”
@RobBehrens1884
comments on the case of a woman who was left ‘confused and terrified’ after doctors failed to realise she was in labour.
7
18
25
A report into how a mental health trust mismanaged its mortality figures was edited to remove criticism of its leadership.
Ombudsman
@RobBehrens1884
will be discussing this, and findings from our recent investigations into avoidable deaths, on tonight's
@BBCNewsnight
👇
Norfolk and Suffolk NHS trust deaths report 'watered down to spare bosses'
1
5
2
8
29
25
How can health and social care leaders create a
#JustCulture
where mistakes lead to learning and improvement?
We'll be exploring this and more at a virtual conference we're co-hosting with
@TheKingsFund
in September.
More details:
#PatientSafety
6
18
25
#MarthasRule
would give patients and loved ones concerned about their care the right to call for an urgent second clinical opinion. We fully support this bolstering of patient voice as a move to reassure parents, carers and patients, and save lives.
Health Secretary Steve Barclay says he will explore the plea of parents calling for "Martha's rule" to make it easier for patients to receive an urgent second medical opinion in hospital.
Dr Ron Daniels from the UK Sepsis Trust spoke to
#BBCBreakfast
8
14
48
4
10
25
"Listening when things go wrong is the very least patients should expect."
In our latest blog, Director of Strategy
@K_Eisenstein
says safe care needs patient voices, but is the NHS ready to listen?
Read more:
14
19
25
Tomorrow we publish the new and improved
#NHSComplaints
Standards. Thanks to everyone who took part in our public consultation on the Standards.
Read our blog to find out how your feedback helped to
#MakeComplaintsCount
:
8
15
24
To mark
#OmbudsDay
we have published a report about the shared challenges ombudsman organisations around the world are facing due to the
#Covid19
crisis. Read the report and find out how organisations are adapting to respond to these challenges:
1
15
23
Today is
#OmbudsDay
! The theme is Ombuds: Unusual name. Important service.
To mark the day
@OmbudAssoc
members are sharing why they think Ombuds provide an important service. Here’s what Parliamentary and Health Service Ombudsman
@RobBehrens1884
says:
1
26
23
Ombudsman
@RobBehrens1884
spoke about how the NHS Complaint Standards help to set out a clear and consistent approach to complaint handling at today’s
@PEN_News
Patient Experience Network National Awards
#PENNA23
@unibirmingham
#NHSComplaints
9
5
24
.
@JamesTitcombe
references our Broken trust report on avoidable harms and
#PatientSafety
at
@HSJptsafety
conference today.
You can read the report on our website:
2
7
23
Today is international
#OmbudsDay
!
Watch
@RobBehrens1884
explain why ombudsman organisations are more important than ever.
👉
2
14
23
We’re calling for urgent action from the Government to make
#PatientSafety
a priority and protect families who’ve suffered tragedies following avoidable deaths.
Our latest report examines cases where patients died due to avoidable errors:
🔴 A “culture of cover-up” is leading to avoidable NHS deaths, with hospitals unable to learn from their mistakes, the Health Ombudsman has warned
6
16
24
6
11
23
The NHS must do more to accept accountability and learn from mistakes when there is serious harm or loss of life.
Our latest report sets out what needs to happen to make
#PatientSafety
more than just a promise.
Read more:
18
7
23
How do
#ombudsman
make a difference?
On
#OmbudsDay
@RobBehrens1884
explains how we are working to promote consistent, high quality complaint handling in the public sector.
2
11
21
⭐NEW REPORT⭐
The first annual Ombudsman’s Casework Report out today includes cases we closed in 2019 about:
➡️ UK government departments & public organisations
➡️ NHS services in England
➡️ mental health services in England
Read it here:
8
25
22
Saying sorry meaningfully when things go wrong is the moral and right thing to do. It is vital for everyone involved in an incident, including patients and staff.
@NHSResolution
has helpful guidance on why, when and how to say sorry:
#DutyOfCandour
#NHS
5
10
22
Read Ombudsman Rob Behrens’ interview about paitent safety in today’s The Times.
He said: “Patient safety is being put at risk by the toxic behaviour of doctors in the NHS.”
Patient safety is being put at risk by the “toxic” behaviour of doctors in the NHS, the health ombudsman has said ⬇️
5
10
24
3
13
21
Today, the House of Lords debated the progress made with NHS
#EatingDisorder
services since we published our report 'Ignoring the alarms' in 2017.
We recommend the Government fulfil its promise to treat eating disorders as a key priority.
Read more:
3
10
22
Many parts of the NHS still put “reputation management” ahead of being open with relatives who have lost a loved one due to medical negligence, Ombudsman
@RobBehrens1884
warns The
@guardian
.
Read more 👇
NHS ombudsman warns hospitals are cynically burying evidence of poor care
12
29
51
17
8
22
‘Deeply distressing’: 118,000 disabled people denied compensation after being underpaid thousands of pounds
Parliamentary health watchdog demands ministers ‘urgently rectify the injustice’
@Independent
7
26
22
Great to see the
#Ombudsman
get a mention in series 4 of
#TheCrown
but it shows just how outdated the need to come to us via an MP is.
40 years on, this continues to be a barrier to people getting justice when they’ve been failed by public services:
6
5
21
Our new report sheds light on the expectant and new mothers who have been failed by
#MaternityServices
.
It features stories from mothers who’ve been put at risk, and practical advice for those who find themselves in a similar position.
Read more:
0
27
21
We’re calling for urgent improvements to the way DNACPR decisions are made and communicated so doctors, patients and their loved ones can make informed choices about
#EndOfLife
care.
Read our latest report:
3
29
23
@NHSLeadership
Q5 Culture is key. A culture that is open, transparent, honest, supportive, accountable, listening, learning, and sharing that learning and best practice. Also one that is inclusive for staff and patients.
#OurNHSPeople
#NHSLeadership
2
6
19
In the latest episode of our Radio Ombudsman podcast, Ombudsman
@RobBehrens1884
and Dr Bill Kirkup discuss
#PatientSafety
and his investigations into public health and maternity services.
Available now on your preferred podcast platform or listen here:
8
11
21
Great visit to
@MFTnhs
learning about how the teams are responding to patient
#feedback
@mftchiefnurse
3
11
20
Good complaint handling means:
1. Getting it right
2. Being customer focused
3. Being open and accountable
4. Acting fairly and proportionately
5. Putting things right
6. Seeking continuous improvement
Read our Principles of Good Complaint Handling:
5
11
21