This month we published decision reports from 14 complaints investigated by the Ombudsman.
Sector breakdown:
- Health: 8
Outcomes:
- Fully upheld: 7
- Some upheld: 1
We made 21 recommendations to public bodies.
Across the majority of these cases, a common theme is the failure to recognise, record or respond adequately to deterioration, risks or significant clinical information. This has resulted in missed opportunities for earlier intervention, safer care, and clearer communication with patients and families.
For example, in one case a care home patient’s deterioration was missed, during a welfare call, delaying their transit to hospital. In another case a patients liver deterioration was not investigated, meaning the patient was not referred to a liver transplant unit.
While the recommendations across these cases are all specific to the individual cases, a number of them highlight the need to ensure safe, consistent, and well‑documented care through timely recognition of risk, accurate communication, and adherence to clinical and organisational standards.