Today we issue two new Public Interest reports into Welsh Ambulance Services University NHS Trust after identifying service failures and serious concerns about the robustness of the Trust’s responses to complaints

Date of article: 18/03/2025

Daily News of: 19/03/2025

Country:  United Kingdom - Wales

Author: Public Services Ombudsman for Wales

Article language: en

We launched two investigations after receiving separate complaints about Welsh Ambulance Services University NHS Trust.

 

Mr B’s case

Mr B complained about care and treatment provided to his late mother, Mrs C (aged 93), after she fell at her home address on 13 September 2022.  An ambulance arrived at Mrs C’s address around 16 hours after the first of 6 emergency calls made by the family.  Mrs C sadly died on 20 September, after being admitted to an ED department.  Mr B complained about how emergency calls about his mother were triaged and prioritised and about advice from Trust staff during those calls.

We found that the Trust’s emergency call handlers correctly triaged and prioritised the emergency calls about Mrs C.  However, a clinician on the Clinical Support Desk (a team of clinically trained practitioners who work as part of the Trust’s control room) should have reviewed Mrs C’s case, identified that she was at serious risk and then considered escalating the ambulance response category.  If this had happened, an ambulance may have been allocated to Mrs C sooner.  This might have reduced the time she spent lying on the floor, which would have been extremely distressing, painful and undignified for her.

It was impossible to be sure whether a quicker ambulance response would have changed Mrs C’s sad outcome.  We decided that this uncertainty amounted to additional injustice to Mr B and his family.

We were very concerned that the Trust missed several opportunities to identify this service failure, and that it only acknowledged failings after receiving the views of our Paramedic Adviser in April 2024.

The investigation also looked at the actions of Swansea Bay University Health Board after Mrs C was admitted to its Emergency Department.  However, that element of the complaint was not upheld.

 

Mrs A’s case

Mrs A complained about care and treatment provided to her son, Mr B (aged 35), in December 2022.  Mr B was at home with Mrs A and his brother, when he collapsed and sadly was later pronounced dead by attending paramedics.  Mrs A complained about how the Trust handled two 999 calls, how the attending paramedics kept a record of events and whether Mr B’s outcome would have been different had the ambulance arrived earlier.

We found that the Trust did not properly manage the two 999 calls made after Mr B had collapsed.  The first call was incorrectly downgraded from Red priority to Green 2.  The second call was also not handled appropriately, with incorrect information given to Mrs A about cardio-pulmonary resuscitation.  As a result, the ambulance arrived to the scene 32 minutes late.  Additionally Mrs A and her other son spent 45 minutes attempting to deliver CPR to Mr B without instruction or support.

We found that the attending paramedic did not enter fully accurate information on the patient clinical record.  The recorded information was inconsistent with that obtained from Mr B’s family and based on estimation.  This was an additional injustice to Mr B’s family.

We could not be sure that earlier attendance of an ambulance would have made a difference, because it was not known when exactly Mr B suffered a cardiac arrest.  However, as there was a small possibility of a different outcome for Mr B, we deemed this as further injustice to the family.

We considered that the Trust’s response to Mrs A’s complaint fell well short of what was expected.  There was a lost opportunity during the Trust’s investigation to obtain key evidence about the care provided.  As a result Mrs A was left with unanswered questions about the events leading to the death of her son.  The Trust also failed to provide us with all relevant evidence at the start of our investigation; some significant pieces of evidence were not provided until several months later.

“I would like to extend my sincerest condolences to both families for their sad losses.

The failures revealed in these reports raise serious concerns about how emergency calls were handled and triaged by the Trust.  The failings led to serious injustice for both families and had correct actions been taken then the treatment and outcomes for both patients could have been different.  I am also concerned about the robustness of the Trust’s investigations of the complaints it receives.

The Putting Things Right Regulations, under which the Trust responded to the complaints, places an obligation upon it to investigate concerns properly, efficiently and openly.  Furthermore the Duty of Candour is now a statutory requirement placed on health boards.

The responses provided by the Trust to both complainants fell well short of what the Putting Things Right Regulations and the NHS Wales Duty of Candour promote and are intended to achieve.

I have made a number of recommendations, accepted by the Trust, to address the failures identified in both investigations.  In the future, the Trust also needs to ensure that it responds openly and honestly to complaints, and that staff involved in the response also need to reflect on both the duty, and their own professional standards obligations when doing so.”

Public Services Ombudsman for Wales, Michelle Morris.

Our recommendations

We made a number of recommendations, which the Trust accepted.  These included:

  • Apologising and providing an explanation to Mr B and Mrs A about the shortfalls in the investigation processes, and paying them £2,750 each for the distress and uncertainty caused.
  • Reviewing its approach to maintaining accurate clinical records to ensure it meets the requirements of The Health and Care Professions Council Standards of Practice.
  • Reminding all clinicians about the importance of good communication with those present at calls they attend.
  • Sharing the reports with:
  1. the Trust’s Complaint Investigation Team to identify learning points
  2. the Trust’s Quality and Patient Safety Committee to include its learning from these recommendations in its Annual Report on the Duty of Candour
  3. appropriate staff to remind them of the importance of fully reviewing information recorded in the Command & Dispatch system at the time of the call.
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Christian Britten Lundblad elected new Ombudsman

Date of article: 19/03/2025

Daily News of: 19/03/2025

Country:  Denmark

Author: Danish Ombudsman

Article language: en

Parliament has elected Christian Britten Lundblad as new Ombudsman. He is succeeding Niels Fenger, who in October 2024 took up a position as judge at the Court of Justice of the European Union.

Christian Britten Lundblad comes from a position as President of the Court of Frederiksberg and has also previously been President of the Court of Aalborg. In addition, 58-year-old Christian Britten Lundblad has been CEO of Ret&Råd, taken up management positions at the Danish Bar and Law Society and been adjunct professor at Aalborg University, among other things. 

‘I am deeply grateful for the trust that Parliament has shown me by electing me as new Ombudsman. It is an institution that plays an essential role in our democratic society and even an institution that has been an inspiration around the world. The Ombudsman institution has – starting off from the Danish Constitutional Act – existed for more than 70 years. I am excited to continue a development – together with the institution’s exceedingly skilful staff – where the institution is relevant and present in times with increased digitalisation and use of artificial intelligence in public case processing, among other things.   

I am very much looking forward to cooperating with Parliament and the state and local administrations in order to protect the legal rights of citizens and businesses in their meeting with public authorities, including contributing to the development of good administrative practice in turbulent times through open dialogue.   

I have naturally – recently in particular – followed the Ombudsman institution’s work closely, and I find that the priority areas already initiated this year are most relevant and topical – so I can hardly wait to get started,’ says Christian Britten Lundblad.

Christian Britten Lundblad will take over as Ombudsman on 1 May 2025 after a period with High Court Judge Henrik Bloch Andersen as temporary Ombudsman.

 

 

CURRICULUM VITAE

 

Christian Britten Lundblad

 

Study and work history etc.

2025- Parliamentary Ombudsman.

2017-2025 President, Court of Frederiksberg.

2008-2017 President, Court of Aalborg.

2006-2007 Acting High Court Judge, Eastern High Court.

2004-2007 Chief Executive Officer, Ret&Råd.

2001-2004 Chief Legal Officer, the Growth Fund (Vækstfonden).

2001 Attorney, Kammeradvokaten.

1997-2001 Head of Office and later Head of Department, the Danish Bar and Law Society.

1996-1997 Head of the Legal Secretariat, the Ministry of Industry, Business and Financial Affairs.

1992-1996 Legal Officer, Department of the Ministry of Justice.

1990-1992 Assistant Attorney, Attorney Søren Theilgård.

1990 Legal Master’s degree from University of Copenhagen.

 

Born 18 October 1966.

Christian Britten Lundblad lives on Østerbro with his wife, and he has two daughters aged 27 and 30.

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The President of the Czech Republic confirmed the creation of the Children's Ombudsman with his signature

Date of article: 10/03/2025

Daily News of: 19/03/2025

Country:  Czechia

Author: Czech Public Defender of Rights

Article language: en

Almost a year has passed since the Government submitted a proposal to amend the Ombudsman Act to the Parliament. It has now been sealed with the President's signature. The law will enter into force on 1 July 2025. Thus, the institution of the Children's Ombudsman will be created on that date. Until the election of its representative, the duties will be carried out by the Deputy Ombudsman, Vít Alexander Schorm. The amendment also extends the ombudsman's mandate to include a so-called "National Human Rights Institution" whose aim is to protect and promote human rights in the Czech Republic. 

On the first day of the holiday season, the newly-approved Children's Ombudsman will start work under the roof of the current Ombudsman's headquarters in Brno. His task will be to promote children's rights in individual cases and at a systemic level. Both ombudsmen will work independently. 

Deputy Ombudsman Vít Alexander Schorm explains the changes that the establishment of the Children's Ombudsman will bring. "The Czech Republic will finally have a figure who will consider the rights of children in a comprehensive way. He will therefore have to carry out a whole range of activities - investigating children's complaints, researching and communicating children's views to other institutions. He will be assisted by an advisory body composed of children, which will be an important source of information on the concerns and aspirations of the younger generation. A completely new element is the power of the Children's Ombudsman to initiate or intervene in selected legal proceedings where the rights of a child are at stake".

 

For example, what will the Children's Ombudsman do?

Investigate children's complaints against the authorities.

Give children quick, effective and clear advice on how to deal with the problem.

Monitor compliance with rights in children's institutions.

Protect children against discrimination.

Monitor the fulfilment of children's rights in different areas of life and to enforce their findings.

Comment on legislation and other documents concerning children.

Initiate legal proceedings if the rights of the child are at stake.

Listen to the younger generation through an advisory body composed of children and pass on their views to other institutions.

Ombudsman Stanislav Křeček points to another important change brought about by the amendment: "In connection with the amendment that has just been signed, there is often talk of a children's ombudsman. Less attention is paid to the fact that the law gives the ombudsman's office new responsibilities in the form of a so-called human rights institution. Until now, the Czech Republic has not had an independent body dealing with human rights in a comprehensive manner. Although the Government Commissioner for Human Rights and a number of non-profit organisations work on this issue, we have so far lacked an institution that would take care of the protection and promotion of human rights in a completely independent manner".

The establishment of a national human rights institution does not entail the creation of a new office. The term refers to the new role of the Ombudsman in protecting and promoting human rights.

 

What will the National Human Rights Institution (or NHRI) be responsible for?

The main activity of the NHRI will be the protection and independent promotion of human rights. The Czech Republic already has a number of institutions for the protection of rights (courts, authorities, police). The NHRI will complement and strengthen the existing system. 

The NHRI will not be similar to a court, it will not decide on disputes, but will monitor and evaluate the human rights situation and make recommendations on how to further improve the implementation of rights. It will deal with systemic issues. Last but not least, it aims to prevent human rights violations.

The Ombudsman already works in this way in a number of areas. He helps to protect people deprived of their liberty (e.g. in prisons) or dependent on institutional care (e.g. in care home for the elderly) from ill-treatment. He addresses the situation of people with disabilities. He provides methodological assistance in the field of discrimination. 

However, the Ombudsman will now also deal with human rights in areas that were previously excluded from his remit. Examples include victims of crime, human rights related to the development of modern technologies (AI, digital exclusion), homelessness and housing affordability.

The NHRI's mandate also entrusts the Ombudsman with tasks such as human rights awareness and education.

The NHRI will also have an Advisory Council composed of scientific, academic and spiritual experts, representatives of civil society, national minorities and other social groups.

Functioning of National Human Rights institutions (NHRIs) abroad

The specific form of NHRIs varies from country to country. In some countries, there is a human rights commission; in others, a research institution monitors compliance with rights. Very often, even abroad, the functions of the NHRI are entrusted to an ombudsperson. Such a solution combines very well the independence of ombudspersons and their mission to protect human rights with the tasks of the NHRI. Such a solution is also advantageous in terms of financial costs.

Who can become the Children's Ombudsman?

A natural person whose knowledge, experience and moral qualities are a prerequisite for the proper performance of his/her duties may be elected as the Children's Ombudsman.

Other requirements are:

citizenship of the Czech Republic;

legal capacity; 

integrity;

at least 35 years of age;

completed university education with a master's degree in law;

at least 5 years of experience in the field of protection of children's rights in the last 10 years

Children's Ombudsman election

The Children's Ombudsman is elected by the Chamber of Deputies for a term of 6 years. The Chamber chooses from 2 candidates proposed by the President, 2 candidates proposed by the Senate and 2 candidates proposed by a body of university representatives.

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La ineficacia de la Administración frena el progreso social de Cataluña

Date of article: 18/03/2025

Daily News of: 19/03/2025

Country:  Spain - Catalonia

Author: Regional Ombudsman of Catalonia

Article language: es

La Administración actual es lenta, complicada, excesivamente burocrática y obsoleta en algunos casos

El tiempo de espera para acceder a determinados servicios es demasiado largo y en ciertos casos se ha incrementado

La institución ha recibido más quejas que el año anterior, con un incremento en las áreas de infancia, servicios sociales, movilidad y transportes, y procedimiento administrativo
 

La síndica de greuges de Cataluña, Esther Giménez-Salinas, acompañada por su adjunto general, Jordi Palou Loverdos, ha entregado hoy al presidente del Parlamento catalán, Josep Rull, el Informe anual de la institución correspondiente al año 2024.

Este informe concluye que la eficacia de la Administración catalana debe mejorar, y es que la ineficacia genera desconfianza en las instituciones, afecta a la calidad de vida de las personas, amenaza la sostenibilidad del estado del bienestar, frena el ascensor social y obstaculiza el desarrollo económico. Para mejorar en eficacia, es imprescindible redimensionar los servicios para adaptarlos a la Cataluña de los ocho millones de habitantes, tal y como se reclamaba en el Informe anual de 2023, pero también hay que simplificar los trámites administrativos y el tiempo de reacción y respuesta ante las demandas de los ciudadanos.

En palabras de la síndica, “una Administración eficaz es aquella que es capaz de ejercer sus funciones respetando los derechos de las personas y la normativa aplicable, pero también la que resuelve los problemas de los ciudadanos, a los que presta un servicio de calidad, con diligencia, profesionalidad y a un coste razonable. Es necesario que la Administración sea más eficaz, empática y amable; que se centre en las personas y no en los trámites”. En este sentido, el informe anual de este año concreta algunas manifestaciones de esta ineficacia que es urgente revertir.

En primer lugar, estamos ante una Administración lenta, que tarda demasiado en dar respuesta a las necesidades de los ciudadanos. Las listas de espera para acceder a algunos servicios y prestaciones se han incrementado en 2024. Por ejemplo, en salud, en octubre de 2024, hay un 9 % más de pacientes en lista de espera para intervenciones quirúrgicas, y un 18 % más para acceder a pruebas diagnósticas o a consultas externas. Si nos fijamos en las residencias para personas mayores y personas con discapacidad, las listas de espera para acceder a estos recursos también han aumentado (un 7 % y un 6,4 %, respectivamente): para acceder a las residencias de personas mayores hay que esperar 1,2 años y a los servicios residenciales para personas con discapacidad, seis años. En vivienda, el tiempo medio de adjudicación de una vivienda social es de casi un año y medio. Y en ayudas para la dependencia, pese a haber mejorado, el tiempo de espera es todavía de nueve meses. Por último, la dilación judicial, explicada por la saturación del servicio, también tiene claras afectaciones sobre las personas y su derecho a la tutela judicial efectiva, y provoca victimización secundaria.

En segundo lugar, la síndica denuncia que la Administración actual es complicada y excesivamente burocrática. Los trámites burocráticos que se exigen para conseguir un servicio están pensados ​​para tener el máximo control e inhibir el incumplimiento. Sin embargo, esto a veces implica que los ciudadanos tengan que entregar la misma documentación en distintas administraciones porque la interoperabilidad reconocida en la normativa todavía no está plenamente garantizada en la práctica. Además, los formularios de uso obligatorio para tramitar determinadas solicitudes están pensados ​​para facilitar la gestión interna de los procesos, pero pueden dificultar el ejercicio de los derechos de las personas.

En el mismo sentido, utilizar un lenguaje complejo –que no es lo suficientemente claro o adecuado– o no dar información suficiente también afecta a la eficacia de una política pública. La dificultad para comprender los trámites o documentos se traduce, por ejemplo, en incumplimientos tributarios que pueden terminar en sanciones económicas. Sin ir más lejos, la implementación de la tasa para la prestación del servicio de gestión de residuos ha generado numerosas quejas en 2024 en este sentido. La institución considera que proporcionar una información adecuada antes de implantar una medida puede ayudar a que tenga una mejor acogida y a que se confíe más en la Administración.

Por otra parte, la Administración no actúa con la máxima eficacia cuando segmenta su intervención por tratar situaciones de vulnerabilidad que a menudo son complejas y requieren ser tratadas desde varios frentes. Desde este punto de vista, resultaría imprescindible integrar la gestión de la renta garantizada de ciudadanía (RGC) y del ingreso mínimo vital, y velar por su compatibilidad con otras ayudas, como las de la vivienda.

En tercer lugar, la Administración actual es obsoleta y utiliza recursos que a menudo no son los más adecuados para conseguir los objetivos que persigue. Un ejemplo de ello es el sistema de protección de la infancia, que todavía pone por delante la institucionalización de los niños y adolescentes. Es sabido que la acogida residencial es especialmente perjudicial para niños menores de seis años, pero, a septiembre de 2024, ha aumentado el número de niños menores de seis años en acogimiento residencial, con 136 menores de tres años y 293 menores de seis años.

El modelo de atención a las personas mayores tampoco responde a las necesidades actuales y no sigue la tendencia europea. Mientras que los datos señalan que la gente mayor prefiere vivir en casa o en una vivienda accesible en caso de dependencia, se ha apostado por aumentar las plazas residenciales (2,6 %), cuando lo que debería potenciarse es una atención domiciliaria integral, y disponer de una red de servicios de apoyo y ayuda coordinados e interconectados.

La Administración tampoco ha dado una respuesta eficaz al problema cronificado de Cercanías, que es el servicio de transporte público con peor valoración, claramente por detrás de otros servicios ferroviarios. Las graves incidencias sufridas en 2024 –por la infraestructura, los trenes o la información ofrecida– han frenado la tendencia creciente de pasajeros de años anteriores, a pesar de haberse mantenido las medidas de accesibilidad económica. Durante 2024, Cercanías de Cataluña registró 127,4 millones de viajeros, cifra muy similar a la de 2023, mientras que otros servicios ferroviarios (FGC o metro) han experimentado crecimientos superiores al 5 %.

En cuarto lugar, la síndica ha puesto sobre la mesa que la Administración a veces está ausente, en el sentido de que no se ha creado a lo largo de los años una política pública lo suficientemente sólida para responder a las necesidades de las personas, o no se llega a todas las personas que lo necesitan. Es el caso, por ejemplo, de la vivienda social: 39.942 viviendas sociales y 97.544 personas inscritas en el Registro de solicitantes de vivienda de protección oficial. También de la RGC o el ingreso mínimo vital: más de la mitad de la población en situación de pobreza material severa no recibe ninguna de estas ayudas. Del mismo modo, tampoco existe un modelo de acogida e inclusión para la inmigración: no se garantiza la equidad y la cohesión social, y la población de origen migrante tiene un acceso desigual a las oportunidades de bienestar social. Y la misma falta de planificación se ve en las políticas para hacer frente a los efectos del cambio climático: solo 206 municipios (39 %) disponen de un plan de emergencias por inundaciones, de los 521 que obligatoriamente deberían tenerlo.

En quinto y último lugar, el informe cita algunos ejemplos de casos en los que la Administración no ha gestionado correctamente los recursos públicos. Un caso importante son las reclamaciones de ingresos indebidos de la RGC y sus problemas derivados: más de 2.300 personas recibieron erróneamente ingresos y después se les reclamó que lo devolvieran. Esto supuso un sufrimiento sobrevenido para unas personas que vieron amenazada su ya precaria economía familiar, pero también un uso indebido de recursos públicos. En este sentido, el informe también destaca la infrafinanciación del sistema educativo, pese a que se ha incrementado un 70 % el presupuesto ejecutado desde 2014. La financiación es lineal, sin discriminar a los sistemas con elevada complejidad.

Cifras destacadas de la institución

Este año se han iniciado 22.825 actuaciones, entre quejas, consultas y actuaciones de oficio. El número de quejas y actuaciones de oficio ha aumentado y se sitúa en 11.214 y 221, respectivamente.

Evolución de las quejas, actuaciones de oficio y consultas

Un año más, las políticas sociales –servicios sociales, educación y salud– constituyen el principal ámbito de intervención del Síndic de Greuges: representan el 43 % del volumen total de quejas y actuaciones de oficio iniciadas. Esto señala la dificultad que tienen las administraciones públicas para dar respuesta de forma adecuada a las necesidades sociales de la población. Sin embargo, se consolida un incremento de las quejas relativas a políticas territoriales (del 15 % al ​​18 %), especialmente a consecuencia de las incidencias en los transportes públicos.

Quejas y actuaciones de oficio iniciadas por áreas

En servicios sociales, destacan las quejas por la demora en la tramitación de la RGC o por la devolución de ingresos indebidos, seguidas por la demora en el reconocimiento y revisión de grado de discapacidad (15 %) y por los servicios residenciales y centros de atención diurna para personas mayores (8 %). En educación, los principales motivos de queja están relacionados con la admisión, la programación de oferta y la segregación escolar (21,6 %); la educación inclusiva (15,3 %), y la tramitación de ayudas, acceso y preinscripción en educación universitaria (10,3 %). Y en salud, destacan las quejas por las listas de espera, que provocan un 20 % más de quejas y actuaciones de oficio.

El segundo ámbito con más intervenciones ha sido el de Administración pública y tributos, como en los últimos años. Ha habido, por ejemplo, una queja colectiva porque el Ayuntamiento de Barcelona ha revocado la licencia a varios clubes sociales de cannabis y una queja colectiva relacionada con la tasa para la prestación del servicio de gestión de residuos.

El tercer ámbito de intervención de la institución ha sido el de las políticas territoriales, sobre todo por las deficiencias del servicio de cercanías y regionales de Cataluña, un tema que afecta gravemente a la movilidad de la ciudadanía y que pone de manifiesto las carencias de transporte público.

En cuanto al cierre de las actuaciones, las cifras indican que se ha detectado irregularidad en el 45,3 % de las actuaciones, lo que supone un incremento del 10 % respecto al año anterior. La institución ha incrementado su nivel de exigencia para conseguir que los ciudadanos, al menos, obtengan una respuesta de la Administración.

Como novedad, también se ha puesto en marcha una web explicativa del informe con acceso a los datos abiertos de la institución.

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Link to the Ombudsman Daily News archives from 2002 to 20 October 2011