Health Service Ombudsman reveals findings of new report

17 July 2023

The Parliamentary and Health Service Ombudsman has this month published a new report revealing that the NHS lacks accountability and compassion towards patients when things go wrong.

Broken trust: making patient safety more than just a promise’ unveils a series of key findings and recommendations for improvement.

The report details that there have been significant developments in patient safety over the last decade, but notes “a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS.” 

Furthermore, experts identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. They then analysed these cases for common themes and conducted in-depth interviews with the families involved.

Key findings

The report found that the physical harm patients experienced was too often made worse by inadequate, defensive and insensitive responses from NHS organisations when concerns were raised.

When they looked at the direct causes of harm, they identified four broad themes of clinical failings leading to avoidable death;

  • failure to make the right diagnosis
  • delays in providing treatment
  • poor handovers between clinicians
  • failure to listen to the concerns of patients or their families.

They also looked at the further harm – sometimes called compounded harm – that happens when families, who have already experienced the devastating consequences of losing a loved one, try to understand what has happened but are met with a poor response from NHS organisations. 

They identified several factors that contribute to compounded harm;

  • a failure to be honest when things go wrong
  • a lack of support to navigate systems after an incident
  • poor-quality investigations
  • a failure to respond to complaints in a timely and compassionate way
  • inadequate apologies
  • unsatisfactory learning responses.

The key recommendations were;

  • Recommendation 1 - Accountability for a robust and compassionate response to harm, which supports learning for systems and healing for families

They advised that the Patient Safety Incident Response Framework (PSIRF) offers a new approach to patient safety investigations, but needs to be accompanied by sufficient monitoring and better support for families.

  • Recommendation 2 - Evidencing that patient safety is a top Government and NHS priority

Focus on creating a  system that is coherent and easier to navigate, based on engagement with patients, families, NHS staff and leaders.

Sharon Banga, principal associate for Shoosmiths’ Serious Injury commented on the report.

Sharon said: “This new report from the Health Ombudsman has revealed some startling findings, but sadly these are issues that we come across day to day in our work supporting clients.

“We often find that many medical negligence claims may have been avoided had the health organisation better investigated and responded to concerns or supported families more fully.  It’s hoped that the recommendations suggested are implemented and more compassion for patients when things go wrong is reflected in the recommended new approach “   



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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