PHSO investigations

Articles in this category

1. Conversations that matter most: improving communication in end of life care (PHSO, 7 July 2026)

   • Investigation
   • End of life care
   • (and 4 more)

     Tagged with:

     • Investigation
     • End of life care
     • Medicine - Palliative
     • Communication
     • Patient / family involvement
     • Patient / family support

   By Patient Safety Learning, 7 July

   • 0 comments
   • 270 views
   • 
   • Added by Patient Safety Learning
   • 7 July

2. PHSO: Prioritising patient safety (Spring 2026)

   • Investigation
   • Recommendations
   • (and 1 more)

     Tagged with:

     • Investigation
     • Recommendations
     • Implementation

   By Patient Safety Learning, 2 June

   • 0 comments
   • 201 views
   • 
   • Added by Patient Safety Learning
   • 2 June

3. PHSO Briefing. Learning from complaints: insights from NHS trust leaders (27 May 2026)

   • Complaint
   • Leadership
   • (and 3 more)

     Tagged with:

     • Complaint
     • Leadership
     • Person-centred care
     • Organisational culture
     • Investigation

   By Patient Safety Learning, 29 May

   • 0 comments
   • 268 views
   • 
   • Added by Patient Safety Learning
   • 29 May

4. PHSO investigation: Kent and Medway Mental Health NHS Trust (30 April 2026)

   • Risk assessment
   • Mental health
   • (and 3 more)

     Tagged with:

     • Risk assessment
     • Mental health
     • Criminal behaviour
     • Discharge
     • Investigation

   By Patient Safety Learning, 30 April

   • 0 comments
   • 268 views
   • 
   • Added by Patient Safety Learning
   • 30 April

5. PHSO: Our strategy 2026 to 2031

   • Investigation
   • Patient safety strategy
   • (and 2 more)

     Tagged with:

     • Investigation
     • Patient safety strategy
     • Complaint
     • Patient harmed

   By Patient Safety Learning, 28 April

   • 0 comments
   • 243 views
   • 
   • Added by Patient Safety Learning
   • 28 April

6. PHSO: Prioritising patient safety (Winter 2026)

   • Complaint
   • Learning disabilities

   By Mark Hughes, 13 February

   • 0 comments
   • 295 views
   • 
   • Added by Mark Hughes
   • 13 February

7. PHSO: Prioritising patient safety (Summer 2025)

   • Complaint
   • Speaking up

   By Mark Hughes, 12 September, 2025

   • 0 comments
   • 438 views
   • 
   • Added by Mark Hughes
   • 12 September, 2025

8. PHSO: Prioritising patient safety (Spring 2025)

   • Imaging
   • Complaint

   By Mark Hughes, 2 June, 2025

   • 0 comments
   • 516 views
   • 
   • Added by Mark Hughes
   • 2 June, 2025

9. PHSO: Prioritising patient safety (Winter 2025)

   • Investigation
   • Complaint
   • (and 4 more)

     Tagged with:

     • Investigation
     • Complaint
     • Maternity
     • Communication
     • Screening
     • Recommendations

   By Patient Safety Learning, 7 February, 2025

   • 0 comments
   • 547 views
   • 
   • Added by Patient Safety Learning
   • 7 February, 2025

10. PHSO. World Patient Safety Day 2024: Improving diagnosis for patient safety (17 September 2024)

    • WPSD24
    • Diagnosis
    • (and 2 more)

      Tagged with:

      • WPSD24
      • Diagnosis
      • Organisational learning
      • Investigation

    By Patient Safety Learning, 26 September, 2024

    • 0 comments
    • 313 views
    • 
    • Added by Patient Safety Learning
    • 26 September, 2024

11. The Ombudsman’s Annual report and accounts 2023 to 2024

    • Investigation
    • Organisational Performance

    By Patient Safety Learning, 19 July, 2024

    • 0 comments
    • 886 views
    • 
    • Added by Patient Safety Learning
    • 19 July, 2024

12. Lessons not learned: A family's lengthy efforts to turn complaints into improvements

    • Hospital ward
    • Home
    • (and 11 more)

      Tagged with:

      • Hospital ward
      • Home
      • Patient
      • End of life care
      • Post-discharge support
      • Transfer of care
      • Discharge
      • Documentation
      • Human error
      • Information processing
      • Organisational learning
      • Organisational development
      • Software

    By Anonymous, 11 June, 2024

    • 2 comments
    • 2,990 views
    • 
    • Comment by Simon Shemilt
    • 6 September, 2024

13. My final Radio Ombudsman podcast: Reflections on seven years in office (PHSO, 28 March 2024)

    • Investigation
    • Transparency
    • (and 2 more)

      Tagged with:

      • Investigation
      • Transparency
      • Patient safety incident
      • Organisational learning

    By Patient Safety Learning, 2 April, 2024

    • 0 comments
    • 499 views
    • 
    • Added by Patient Safety Learning
    • 2 April, 2024

14. A priority for all: Rob Behrens reflects on patient safety in 2023 (PHSO, 27 December 2023)

    • Investigation
    • Patient harmed
    • (and 7 more)

      Tagged with:

      • Investigation
      • Patient harmed
      • Diagnosis
      • Handover
      • Communication problems
      • Patient engagement
      • Organisational culture
      • Speaking up
      • Complaint

    By Patient Safety Learning, 2 January, 2024

    • 0 comments
    • 721 views
    • 
    • Added by Patient Safety Learning
    • 2 January, 2024

15. Parliamentary and Health Service Ombudsman: Hospital’s failing led to postman’s death following football injury (13 November 2023)

    • Accident and Emergency
    • Patient death
    • (and 4 more)

      Tagged with:

      • Accident and Emergency
      • Patient death
      • Investigation
      • Diagnosis
      • Decision making
      • Complaint

    By Mark Hughes, 13 November, 2023

    • 0 comments
    • 1,211 views
    • 
    • Added by Mark Hughes
    • 13 November, 2023

16. Ombudsman writes to Health Secretary calling for statutory inquiry and action on patient safety in wake of Letby trial (PHSO, 23 August 2023)

    • Investigation
    • Organisational culture
    • (and 7 more)

      Tagged with:

      • Investigation
      • Organisational culture
      • Patient harmed
      • Patient death
      • Baby
      • Nurse
      • Speaking up
      • Whistleblowing
      • Duty of Candour

    By Mark Hughes, 24 August, 2023

    • 0 comments
    • 872 views
    • 
    • Added by Mark Hughes
    • 24 August, 2023

17. Information about financial remedy and severity of injustice scale (PHSO)

    • Complaint
    • Investigation
    • (and 2 more)

      Tagged with:

      • Complaint
      • Investigation
      • Redress
      • Patient harmed

    By Patient-Safety-Learning, 17 July, 2023

    • 0 comments
    • 2,636 views
    • 
    • Added by Patient-Safety-Learning
    • 17 July, 2023

18. Response to PHSO report – Broken trust: making patient safety more than just a promise (Patient Safety Learning, 3 July 2023)

    • Investigation
    • Organisational culture
    • (and 9 more)

      Tagged with:

      • Investigation
      • Organisational culture
      • Safety culture
      • Just Culture
      • Patient harmed
      • Patient engagement
      • Patient / family involvement
      • Communication problems
      • Patient death
      • Organisational learning
      • Duty of Candour

    By Patient Safety Learning, 4 July, 2023

    • 1 comment
    • 2,397 views
    • 
    • Comment by LowTech
    • 15 July, 2023

19. Broken trust: making patient safety more than just a promise (PHSO, 26 June 2023)

    • Investigation
    • Organisational culture
    • (and 11 more)

      Tagged with:

      • Investigation
      • Organisational culture
      • Organisational learning
      • Just Culture
      • Safety culture
      • Patient harmed
      • Patient / family involvement
      • Patient engagement
      • Patient death
      • Communication problems
      • Patient / family support
      • Transparency
      • Harmed Care Pathway

    By Patient Safety Learning, 29 June, 2023

    • 0 comments
    • 1,889 views
    • 
    • Added by Patient Safety Learning
    • 29 June, 2023

20. PHSO - Our strategy 2022 to 2025 (5 April 2022)

    • Investigation
    • Complaint
    • (and 1 more)

      Tagged with:

      • Investigation
      • Complaint
      • UK

    By Patient-Safety-Learning, 30 August, 2022

    • 0 comments
    • 1,563 views
    • 
    • Added by Patient-Safety-Learning
    • 30 August, 2022

21. PHSO investigation - Man died after doctors missed opportunities to identify abnormalities on his X-ray (20 July 2022)

    • Imaging
    • Diagnostic error
    • (and 2 more)

      Tagged with:

      • Imaging
      • Diagnostic error
      • Investigation
      • Patient death

    By Patient-Safety-Learning, 4 August, 2022

    • 0 comments
    • 964 views
    • 
    • Added by Patient-Safety-Learning
    • 4 August, 2022

22. PHSO: Failure to act on sepsis led to man’s death, Ombudsman finds (3 March 2022)

    • Sepsis
    • Deterioration
    • (and 4 more)

      Tagged with:

      • Sepsis
      • Deterioration
      • Monitoring
      • Negligence claim
      • Patient death
      • Communication

    By Patient-Safety-Learning, 3 March, 2022

    • 0 comments
    • 1,877 views
    • 
    • Added by Patient-Safety-Learning
    • 3 March, 2022

23. Northern Ireland Public Services Ombudsman: Investigation of a complaint against the Belfast Health and Social Care Trust (July 2020)

    • Investigation
    • Patient death
    • (and 8 more)

      Tagged with:

      • Investigation
      • Patient death
      • Northern Ireland
      • Observations
      • Learning disabilities
      • Commissioner
      • Prescribing
      • Complaint
      • Patient / family involvement
      • Nutrition

    By Patient Safety Learning, 17 June, 2020

    • 0 comments
    • 1,333 views
    • 
    • Added by Patient Safety Learning
    • 17 June, 2020

24. PHSO: Ignoring the alarms – How NHS eating disorder services are failing patients (December 2017)

    • Mental health unit
    • Mental health - CAMHS
    • (and 6 more)

      Tagged with:

      • Mental health unit
      • Mental health - CAMHS
      • Internal major
      • Patient death
      • Adolescent
      • Young Adult
      • Eating disorder
      • Organisation / service factors

    By Heather PHSO, 4 March, 2020

    • 0 comments
    • 2,071 views
    • 
    • Added by Heather PHSO
    • 4 March, 2020

25. Parliamentary and Health Service Ombudsman - 'How can we help you?'

    • Patient
    • Complaint
    • (and 3 more)

      Tagged with:

      • Patient
      • Complaint
      • Investigation
      • Policies / Protocols / Procedures
      • Standards

    By Claire Cox, 12 February, 2020

    • 0 comments
    • 1,547 views
    • 
    • Added by Claire Cox
    • 12 February, 2020