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Parliamentary and Health Service Ombudsman – update

Published 10 December 2015

Parliamentary and health service ombudsman

This week the Parliamentary and Health Service Ombudsman (PHSO) published its review into the quality of complaints investigations where serious or avoidable harm had been alleged. The PHSO reviewed 150 complaints and spoke to 170 NHS complaints managers from across the country.

The PHSO found that:

  • the process of investigating is not consistent, reliable or good enough
  • staff do not feel adequately supported in their investigatory role
  • there are missed opportunities for learning.

The PHSO found that 40% of investigations it reviewed failed to identify failings or causes of failings. In 73% of the investigations, the PHSO found failings where the trust did not.


The review highlights a lack of consistency in investigation methods. The methods appear to be left to the investigator to decide as evidenced by almost a fifth of investigations lacking reference to medical records, interview transcripts or statements.

Ultimately, this often leads to families being left with an unacceptable experience. The PHSO found that in 41% of cases the trusts did not provide complainants with an adequate explanation of what happened and why.

To improve we need to learn and address system failures. If undertaken well, complaints investigations can help families, improve patient care and improve staff experiences.

On 6 November 2015, Charlie de Montfort published a blog which explores methods of triangulation that can be used to ensure accuracy and reliability across investigations.  By ensuring that investigators are comprehensibly trained, they are equipped to identify and address the underlying issues of what went wrong and why.


The key learning points from our systematic incident investigation training are that investigations need to demonstrate:

  • independence
  • competence
  • authority and credibility
  • cultural sensitivity
  • objectivity.

We are also helping trusts ensure that lessons are being learnt across the organisation via our learning lessons diagnostic tool.

Let’s make 2016 a time for a change.

If you would like to learn more about Parliamentary and Health Service Ombudsman then please contact our Ed Marsden on 020 7494 5670 or [email protected].

Verita is an independent team providing investigations consultancy work with organisations in a variety of sectors throughout the UK
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