Thousands affected by Student Loans Company system error

Date of article: 20/03/2025

Daily News of: 21/03/2025

Country:  United Kingdom

Author: Parliamentary and Health Service Ombudsman

Article language: en

Thousands affected by Student Loans Company system error JamesL
20 March 2025

Thousands of students have been hit by a system error from the Student Loans Company (SLC) which meant their loans were not written off, the Parliamentary Ombudsman has found.

The Ombudsman has called on the SLC to make improvements to its Advanced Learner Loans (ALL) processes after a systemic issue affected around 4,000 students.

ALLs give students access to university when they do not have relevant qualifications such as A-Levels. Once the degree is completed, the loan is written off.

Jennie Bradbury, 38, from Stoke on Trent, received a loan for tuition fees worth £2,395 in July 2013 to fund a one-year access to higher education diploma in health at Stoke on Trent College.

Jennie went on to study a midwifery degree at Keele University. Her loan should have been cancelled in September 2019 when she completed her degree, but it took the SLC four years to cancel it.

Jennie contacted the SLC towards the end of 2019 to ask when her loan would be written off. She was told it would happen automatically and she would be notified. 

The SLC then contacted Jennie in June 2020 and again in May 2021 to tell her the loan had still not been written off.

After repeatedly contacting the SLC, Jennie received an apology and a £25 payment.

Jennie remained unsatisfied and later complained to the Independent Assessor for the Department for Education in August 2022. It recommended the SLC increase this payment to £200 and admitted the system issue was yet to be resolved. Jennie then complained to her MP, who referred it to PHSO in February 2023.

The Ombudsman found the SLC should have written off Jennie’s loan in September 2019 but delayed doing so until September 2023 following an investigation. The SLC also failed to transfer the outstanding balance from the ALL loan to her graduate loan account.

The SLC has now written off all outstanding loans which affected approximately 4,000 accounts.

The Ombudsman recommended the SLC apologises to Jennie, provides a plan of how it will communicate clear timeframes to any customers with ALL accounts who have raised an issue about their loans not being written off, and provide an extra £200 financial redress to her. The SLC has complied with our recommendations.

Jennie said:

“It was really frustrating. It made me really anxious as well because I was worried about the interest that was going onto my other loan and how it was going to affect it when I was paying it back.

“As if it isn’t hard enough being a student, you’re starting a new job just after a degree, you’re then trying to constantly chase this up to see what effect it’s going to have.

“Never getting a reply was the worst bit. Every time I would ring, they would say ‘we’ll get someone to get back in touch with you’ and then nobody did, or nobody would have an update – that was the most frustrating part.

“I think some people probably haven’t even realised their loan hasn’t been written off.

“As soon as the Ombudsman started to look into it and got the ball rolling, it didn’t take long for the debt to be refunded. I’m very happy.”

Parliamentary and Health Service Ombudsman Rebecca Hilsenrath said:

“Repaying a student loan is familiar to many university graduates, but the error made in this case caused real upset and frustration for Jennie. The problem was exacerbated by the fact that no one listened and no one did anything. Thousands of students have been affected by this and have been paying off a loan which should have been written off.

“We always seek to encourage learning from our investigations for organisations to take forward and improve their services. Complaints are an important source of learning and improvement. Following our investigations, thousands of people have had these loans written off. We welcome the steps which the Student Loans Company is taking to stop these system errors happening again.” 

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Patients being harmed due to repeated mistakes in reading scans

Date of article: 20/03/2025

Daily News of: 21/03/2025

Country:  United Kingdom

Author: Parliamentary and Health Service Ombudsman

Article language: en

Patients being harmed due to repeated mistakes in reading scans KHoward
20 March 2025

Repeated failings in the way scans are read are leading to delays in cancer diagnosis, unnecessary operations and avoidable deaths, England’s Health Ombudsman has warned.

Since publishing a report four years ago which highlighted mistakes in the way digital images are read and used as a diagnostic tool, the Parliamentary and Health Service Ombudsman (PHSO) has upheld or partly upheld more than 40 cases in which similar failings were found.

The most common issues are doctors failing to identify an abnormality, scans not being carried out or delayed, and results not being properly followed up.

Examples of the impact of these failings include a 10-month delay in cancer being diagnosed which significantly harmed the person’s chance of survival. In another case, serious pelvic sepsis was not identified which led to an avoidable death, and in a separate case, a missed ankle fracture led to an avoidable operation.

The Ombudsman is calling for greater learning when things have gone wrong to prevent the same mistake being made.

Rebecca Hilsenrath KC, Parliamentary and Health Service Ombudsman, said:

“Each of the cases we have investigated and upheld represent a real person whose life has been impacted by failings in care. They are also all instances where the organisations involved failed to identify that anything had gone wrong.

 

“When things go wrong, there must be learning at both an organisational and wider systemic level. In our 2021 report we recommended a system-wide programme of improvements for more effective and timely management of X-rays and scans. While we have seen some progress in this area, unfortunately we are still seeing instances where people’s care is sub-optimal, often with devastating consequences.

 

“It is critical that action is taken to improve the digital infrastructure of the NHS and make sure people are correctly diagnosed and swiftly treated. NHS leaders need to address this as the important patient safety issue it is.”

In one of the investigations, PHSO found that doctors at Wexham Park Hospital repeatedly failed to diagnose a grandfather’s cancer which delayed his treatment and left him in prolonged pain.

He was diagnosed with bowel cancer on his fifth visit to A&E within three months, by which time he was in extensive pain. The 82-year-old took his own life, leaving a note saying he could no longer deal with the pain.

PHSO found that clinicians failed to report a small bowel lesion from a scan in August 2021. This failure led to a six-week delay in diagnosing the obstruction and in carrying out surgery, and prolonged the pain the patient was enduring.

The Ombudsman concluded that the failings in care were probably contributory factors to the patient’s decision to end his life.

PHSO recommended that the Trust pay the man’s daughter £4,000, apologise, and develop an action plan to address the failings identified. The Trust has agreed to comply.

The man’s daughter said:

“I really tried to get the doctors to listen. I had a feeling something was wrong and I pleaded numerous times for them to keep him in the hospital but they just kept discharging him and not doing anything to help him.

 

“My dad was clearly thin and clearly vulnerable and they didn’t care. Doctors should be prioritising vulnerable people because the outcome can be so much worse for them, and they should be held accountable if they don’t. I feel that my dad killed himself because of failures in his care. I have no father now and I have to live with that. I am completely on my own now.”

Read the full case summary.

In another investigation, PHSO found that a cancerous tumour was misidentified as benign by Kings College London Hospital despite repeated scans showing it was malignant.

The tumour was identified as a glioblastoma, a very aggressive type of cancerous tumour found in the brain, by a hospital in Tenerife after the man, who was 54, became unwell while on holiday there.

After returning home to Gillingham, he attended a hospital where staff carried out further scans that also identified the tumour and referred him to Kings College London Hospital, a specialist referral centre for brain cancer.

Kings College staff reviewed the scans and downgraded the diagnosis, saying the tumour was non-cancerous. The man’s care was consequently deemed non-urgent during the pandemic and he was not offered chemotherapy or radiotherapy.

His cancer was missed again during further tests. During an operation in October 2020 to remove the tumour that doctors believed to be benign, he suffered a massive bleed which led to severe respiratory failure, brain damage, kidney failure, deep vein thrombosis and lung clots. He died in hospital four weeks later.

PHSO found that if the cancer had been correctly identified this surgery would have been offered nine months earlier. If recovery went well, surgery would have been followed by chemotherapy and radiotherapy.

While this type of cancer has a poor survival rate, the Ombudsman found that his life might have been extended for a few more months had the diagnosis been made earlier.

PHSO recommended the Trust pay the family £3,500. They also recommended the Trust apologise and create an action plan to prevent this from happening again. The Trust has agreed to comply.

The man’s brother, 56, from Tunbridge Wells, said:

“When my brother collapsed in Tenerife, the hospital immediately identified the tumour for what it was and even offered to remove it. But my brother wanted to come home, he thought the best place for him to have the treatment was in the NHS.

 

“The tumour growing should have been a warning sign and I cannot understand why they kept insisting it wasn’t cancerous. They should have assumed the worst, not hoped for the best. It felt like they were taking a blasé approach to his symptoms.

 

“I came to the Ombudsman because something had gone wrong with my brother’s care and I wanted to know that at least a learning process could come out of it. I wanted Kings College to acknowledge their mistakes so that I can stop picking at the scab of trying to understand what happened to him and remember my brother as he was when he was alive.”

Read the full case summary.

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