• Good communication is essential to delivering high-quality, compassionate end of life care, says new Ombudsman report.
• Government is urged to prioritise end of life care as part of its 10 Year Plan reforms by prioritising it in the roll out for a Single Patient Record and via training to support professionals to have critical conversations about patients’ prognosis and wishes.
• One case involves a man who was not informed for a month after it was confirmed by tests that his cancer had spread. He found out accidentally and died two months later.

Patients nearing end of life are being failed by poor, unclear communication that compromises care and compounds grief, according to a new report by England’s Health Ombudsman.

The Parliamentary and Health Service Ombudsman (PHSO) is urging the Government to prioritise improvements to end of life care as part of its NHS reforms. 

The report, Conversations that matter most: improving communication in end of life care, highlights widespread failings in the way professionals working in NHS end of life care communicate with patients, families and carers, and between teams and care settings. 

In one case, a Trust failed to clearly and promptly inform a man that his cancer had spread and was terminal. He found out by accident from his GP.

The Ombudsman’s newly published five-year strategy has committed to improving communication in public services as a way of rebuilding trust between the citizen and state. Too often, patients and families are not listened to or communicated with clearly. When the patient voice is not heard, opportunities to resolve issues early are lost, avoidable harm can be repeated, and complaints become harder to resolve and learn from.

Ombudsman Paula Sussex CBE said, 

“For more than a decade, we have highlighted problems with end of life communication. But disturbingly, too many people are still being let down. At their most vulnerable moments, patients and families should be able to rely on care that is clinically effective, compassionate and honest. 

 

“However, our report shows poor communication is causing avoidable distress for those receiving care, their loved ones and the professionals caring for them. Listening to its patients is one of the most powerful tools the NHS has to prevent harm. Patient voice must be at the heart of improvement.

 

“There needs to be better information-sharing, record-keeping, and training that gives staff the confidence and support to have timely, honest conversations about prognosis and people’s wishes. As the Government pushes forward with its plans to develop a Single Patient Record across the NHS, we urge them to prioritise end of life care as an area for roll out. 

 

“Compassionate communication should be a fundamental part of quality care and it needs to be led by the profession themselves. Patients and families deserve care that is clear, coordinated and empathetic, while professionals working deserve systems that support them to deliver it.”

Communication failures remain the most recurring theme in Ombudsman investigations. We have repeatedly raised concerns about communication in end of life care, including in our 2015 report, Dying without dignity, and our 2024 report on DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decisions.

Casework analysed for this new report shows patients, and their families are often left ill-informed about their prognosis, with poor discussions about treatment, care preferences, where they wish to die and who they want involved in decisions about their care. 

Families are often not told clearly or early enough that their loved one is deteriorating or approaching the end of life, further adding to their grief after their relative has died.

End of life care can be complex and involve multiple teams and settings such as wards, hospices and care homes. Poor communication between these teams affects continuity of care, delays decision-making and leaves patients and families constantly having to chase for updates. 

The Ombudsman spoke to clinicians to understand more about the barriers to good communication. Many described the emotional burden of difficult end of life conversations and the challenges of communicating effectively when faced with time pressures, limited support and access to the right information. 

One case shared in the report involves a man who visited his GP in March 2021 with symptoms of rapid weight loss and abdominal pain and was referred to hospital. A biopsy and scan revealed he had colorectal cancer that had spread to his liver.

The man was not informed the cancer had spread to his liver by hospital clinicians. He found out when his GP, assuming the patient had been informed by the hospital Trust, mentioned it during an appointment in April to discuss pain management. 

The Trust did not directly tell him that his cancer had spread for a month after the tests had confirmed it. He died in June. Because of the lack of clarity about his prognosis and delay in informing him, he was denied additional time to make end of life arrangements. 

The man’s wife said, 

“What stays with me most is how alone and powerless we felt. We weren’t kept informed, we didn’t understand what was happening, and we lost precious time that we can never get back. It was devastating for my husband, and for those of us who loved him, it has left a lasting pain, guilt and loss of trust that never really goes away. That my husband had to suffer will stay with me for the rest of my life.

 

“What we needed was simple, to be told what was going on, for the teams to speak to each other, and for someone to act sooner. It doesn’t cost anything to talk to families and let them know what is happening, but that basic communication was missing. At the end of life, people only get one chance to receive the right care and support, and no family should be left feeling this helpless. The NHS failed us.”

Dr Sarah Holmes, Chief Medical Officer at Marie Curie and consultant in palliative medicine, said:

“Deeply troubling but not surprising, this report shows why too many families are left haunted by a loved one’s death. It highlights fragmented care, overstretched staff, and missed chances to recognise — or tell someone — they are dying. 

 

“That is why Marie Curie is partnering with the NHS to embed teams in emergency departments and GP practices — identifying people earlier, supporting staff, and helping families get care plans and conversations sooner. 

 

“These services must be rolled out nationwide. The UK Government’s Palliative and End of Life Care Modern Service Framework could help fix a broken system — but only with a transformation fund to drive joined-up care. 

 

“Change is long overdue. Families saying goodbye do not get a second chance — and successive governments have had too many.”

The importance of improving communication at end of life care extends beyond the NHS. The Local Government and Social Care Ombudsman will shortly publish a report examining end of life care in the social care sector, highlighting the importance of person-centred care, joined up services and clear, compassionate communication. 

This reinforces the need for improvements across health and social care to ensure people approaching the end of their life, and those close to them, receive coordinated, dignified care.

During Armed Forces Week the Local Government and Social Care Ombudsman is urging councils across England to ensure they are genuinely meeting their legal duties to military families - after finding that Shropshire Council left an armed forces child without specialist education support for five months.

The family moved to Shropshire in February 2025 as part of a military posting. Because the child had an Education Health and Care (EHC) Plan, Shropshire Council had been informed of the move two months in advance. Despite this, it failed to arrange a school placement or put interim education in place when the family arrived. After limited online schooling arranged by the previous council ended in April 2025, the child had no education at all for several months at the start of his GCSE preparation course.

The mother made repeated attempts to contact the council, to which its responses were described by the Ombudsman as "woefully inadequate". When she formally complained, the council took four months to provide a final response, offered no adequate remedy, and made no reference to the Armed Forces Covenant.

Amerdeep Clarke, Local Government and Social Care Ombudsman, said:

"Armed Forces Week is a moment for the nation to recognise the sacrifices made by those who serve. But recognition must be matched by action. The Armed Forces Covenant is not a gesture - it is a legal duty, and it exists precisely because service families already face considerable disruption through no fault of their own. Senior leaders sign up to covenants, but what matters is that this commitment is felt in the everyday decisions that affect people's lives.

“When a family moves as part of a military posting, the very least they should be able to expect is that the council has their child's support in place from day one. In this case, the council had two months' notice and still left a child with significant special educational needs without his specialist provision for the best part of half a year during the critical start of his GCSE studies.

"I would urge every council in England to look at this case and satisfy themselves that they are genuinely meeting their obligations to armed forces families. The Covenant is not a box-ticking exercise."

The Armed Forces Covenant places a legal duty on councils to ensure military families face no disadvantage in the provision of public services. The SEND Code of Practice specifically requires that transitions are well managed for service children with special educational needs, and that councils work proactively to ensure provision is in place from the moment a child arrives.

Shropshire has around six military bases within its boundaries. The Ombudsman's report notes that the council's own Armed Forces Covenant Action Plan 2025–29 acknowledges outstanding challenges around SEN provision for service children, making the failure to act in this case all the more concerning.

The Local Government and Social Care Ombudsman remedies injustice and shares learning from investigations to help improve public, and adult social care, services. In this case the council has agreed to apologise and pay the mother £3,000 to reflect the missed provision.

The Ombudsman has the power to make recommendations to improve processes for the wider public. In this case the council will review its Armed Forces Covenant Action Plan and implement changes to SEND procedures to ensure service children with SEND do not experience gaps in their education when moving into Shropshire.

Today (24 June) we are launching new standards for complaint handling which must be followed by all government departments and relevant arm’s length bodies.

The new standards require detailed recording of complaints alongside analysis to identify learning and drive improvement. An oversight role for non-executives in scrutinising complaint culture and performance is also a key change. 

Public bodies are expected to consider the information they have about complaints alongside whistleblowing information, internal audit reports, staff grievances or concerns to help identify where more systemic failings may have occurred.

The standards are supported by the sector specific Model Complaint Handling Procedures (MCHP), which will ensure a more consistent, person-centred approach to managing complaints across. New online training resources also support staff who have a role in managing and overseeing complaints.

Margaret Kelly, the Northern Ireland Public Services Ombudsman, said: 

“The new approach seeks a change in culture. It emphasises that public bodies are expected to acknowledge where things have gone wrong and seek to put them right. 

Too often public bodies have received complaints which indicate a wider problem, but they have not been recorded or acted upon, and unfortunately, we have often seen this come out in subsequent public inquiries. It is critical that the civil service and their arm’s length bodies embrace the change in culture and use complaints as an opportunity for openness, improvement and learning.” 

Commenting ahead of the launch, Head of the Northern Ireland Civil Service, Jayne Brady said:

"Publication of the Model Complaint Handling Procedures marks an important milestone in how government departments and arm's length bodies listen and respond to the people they serve. 

By adopting them, we are making a clear public commitment to transforming the culture around complaints across the entire civil service which will ensure that when things go wrong, we acknowledge it, learn from it, and do better."

The overhaul follows the findings from a recent survey which shows that while more than half of the population (55%) felt unhappy with a public service over the last five years, fewer than half of those people made a complaint.

Respondents told the survey that they felt the system was too hard to navigate, with 71% of those who chose not to complain saying it wouldn’t change anything. 

Donna Ockenden has published her review into Nottingham University Hospitals NHS trust.

Commenting on the report, Parliamentary and Health Service Ombudsman Paula Sussex said:

“This report adds to an overwhelming body of evidence that maternity services are failing women and families in ways that are repeated and preventable.
 

“For years, reviews have highlighted the same issues - failures in communication, not listening, delays in diagnosis, and poor postnatal care. Yet too often these warnings and any lessons have not translated into lasting improvement, resulting in repeated harm.
 

“While many NHS staff work tirelessly to provide excellent care, every woman and baby deserves safe, compassionate care, every time. It is vital now that we focus on fixing the service. NHS leaders must ensure these findings lead to real, sustained action across all Trusts.
 

“Listening to women and families is one of the most effective ways to prevent harm and improve care. We owe it to those affected not just to recognise these failures, but to ensure they lead to meaningful and lasting change.”

A disabled teenager was left unable to use their wheelchair or access essential medical equipment following major surgery, because of avoidable failures by a London council, the Local Government and Social Care Ombudsman has found.

The Ombudsman’s investigation into London Borough of Barking and Dagenham found that a family including a teenager, who is unable to walk and has extensive care needs, remained in unsuitable accommodation for almost 18 months due to accumulated delays and other failures by the council.

A representative on behalf of the family told the council the teenager could not use their wheelchair inside the flat, there was no space for a mobile hoist to help move them, and all  changes of the teenager’s position had to be carried out manually, posing a health and safety risk to the teenager and their carers.

After being clearly informed the property was unsuitable, Barking and Dagenham failed to consider whether the family might be legally homeless. It also delayed by five months completing an Occupational Therapy (OT) assessment, requested by the teen’s hospital. This meant they underwent major surgery before the council had gathered the basic information needed to understand the family's circumstances. Following the surgery, all transfers had to be completed by hoist – equipment the family had no room to store or use in their current home.

The council also failed to properly explain a decision about the family’s rights to housing or inform them of their right to appeal. There was also an eight-month delay in the council issuing a formal complaint response.

Amerdeep Clarke, Local Government and Social Care Ombudsman, said:

"This case is a stark reminder of what can happen when processes fail a vulnerable child. The teenager underwent major surgery and came home to a property where they could not use their wheelchair, could not access their medical equipment, and could not move around with the dignity and independence they deserved. That is a deeply troubling outcome, and one that may have been avoided had the council acted promptly.

"There are clear lessons here for all councils. The legal duty to consider whether a family may be homeless is triggered at a low threshold. It does not require a formal application or a visit to a specific department. Occupational Therapy assessments must be completed without undue delay, particularly where a person's medical needs are pressing. And when residents raise complaints, councils must respond fully and on time.

"I welcome the fact that Barking and Dagenham has accepted all of our recommendations. The action plans they have committed to, on homelessness and OT waiting times, should prevent similar injustice in the future. I would encourage councils across the country to reflect on this case and consider whether their own processes meet the standards residents should expect."

The Local Government and Social Care Ombudsman remedies injustice and shares learning from investigations to help improve public, and adult social care, services. In this case the council has agreed to apologise to the family and pay them £1,200. It will also meet with them to explore their housing options.

The Ombudsman has the power to make recommendations to improve processes for the wider public. In this case the council has agreed to improve guidance to complaints officers. It has also committed to producing action plans, with senior-level monitoring, setting out how it will identify potential homelessness cases at any point of contact and reduce OT waiting times.