The Care Quality Commission (CQC) has today published it's annual State of Care report.

The report assesses health care and adult social care in England. This year's report highlighted inequalities across the system leading to fractured care. 

Paula Sussex CBE, Public Service Ombudsman, said:

"The concerns raised by the CQC; fragmented care, lengthy waiting times amid rising demand for services – particularly in mental health, and regional variations in care are all sadly familiar from Ombudsman investigations. Our evidence has found that the root cause of these issues is often the way in which services are designed, organised, and delivered. 

“To improve people’s access to and experience of care, we need to see improvements in the way that public services are designed around the needs of people who use them and improvements in the way that their experience of the service can be heard and acted on.”

Ombudsman schemes matter because they give people a voice and provide an alternative route to justice.

Ombuds Day 2026 provides an opportunity to celebrate the value of Ombudsmen with our colleagues across the UK and Ireland.

The Government has today published its independent review into mental health conditions, ADHD and autism. It found that 

Ombudsman Paula Sussex said:

“The Government’s independent review provides an important opportunity to consider how the system responds to rising demand for mental health, ADHD and autism services. Right now, the system is too complex and inconsistent. Our recent report on improving ADHD and autism services found people facing long waits, confusing pathways and inconsistent access to care. This has been mirrored in the findings of the Government’s review.

“Many of the recommendations from our report are reflected in the Government’s review, in particular our call for diagnostic only assessment providers to be regulated by the CQC, updated NICE guidelines, improved data collection and digital tools. The focus must be on delivering quality, sustainable services with people at their heart, including via a Right to Choose pathway that can meet demand. I look forward to working with the Department of Health and Social Care and NHS England as they take forward the review’s findings.”

A Lancashire homecare provider failed to follow its own procedures after a service user expressed suicidal intent, the Local Government and Social Care Ombudsman has found, in a decision that highlights lessons for the wider care sector on recognising and responding to risk.

The Ombudsman investigated a complaint against Promedica24 (Lancashire) Limited after a live-in care worker did not escalate concerns when a man in their care expressed an intention to take his own life. The man later took an overdose and died in hospital a short time later.

The investigation found the care worker failed to follow the provider's own Self-Harm and Suicide Awareness Policy, which required staff to treat any expression of suicidal intent as an emergency, contact the emergency out-of-hours line, and notify family members. The care worker also demonstrated a lack of understanding of medication risk, having casually told the man's daughter that he would have had to “eat the whole package” of the medication involved to “finish him off”.

The Ombudsman found the care provider's actions amounted to a breach of regulations requiring providers to assess and mitigate risks to people's health and safety, and to treat people with dignity, respect and compassion.

The care provider subsequently refused to investigate a complaint from the daughter after her father's death, on the grounds that a coroner's inquest had already considered the circumstances. The Ombudsman found this was inconsistent with the provider's own complaints policy and amounted to a further breach of regulatory standards on complaint handling.

While the Ombudsman could not say whether the outcome for the man would have been different had staff acted correctly, the failure to escalate his concerns meant his daughter lost the opportunity to be involved in decisions about her father's care, causing her avoidable distress.

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

"This is a deeply distressing case, and I want to extend my sympathy to the family for their loss. When someone in a carer's charge expresses thoughts of taking their own life, that must always be treated as an emergency. Providers have clear policies for exactly this reason, and it is vital that staff are trained and confident enough to follow them under pressure.

"Equally concerning is that when the family sought answers through a complaint, they were turned away. A coroner's inquest and a complaint investigation serve very different purposes, and providers should not use one as a reason to avoid the other. Families deserve to have their concerns heard and properly investigated.

"I hope this case prompts all care providers to reflect on how confident their staff are in recognising and escalating risk, and how robust their complaints processes are, so that families are not left with unanswered questions at the worst possible time."

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 care provider has agreed to apologise to the daughter for the distress caused by its failure to escalate her concerns and to properly investigate her complaint.

The Ombudsman has the power to make recommendations to improve processes for the wider public. In this case the care provider has agreed to remind relevant staff of the need to accept and investigate complaints in line with its own complaints policy, reinforcing how staff should respond sensitively to bereaved families. It will also arrange refresher training for staff on recognising and responding to suicide risk, understanding medication risks, and communicating sensitively with service users and their families.

Anyone affected by the issues raised in this case can contact Samaritans free, any time, on 116 123, or the Campaign Against Living Miserably (CALM) on 0800 58 58 58.

The Ombudsman offers a free online toolkit for care providers (asctoolkit.lgo.org.uk) to help them become "complaints confident".