England’s Health Ombudsman has warned of concerns about the diagnosis and care of stroke patients after the number of its investigations rose by two-thirds. 

The Ombudsman is urging clinicians to act quickly when they suspect a stroke, even if the patient presents with atypical symptoms. It is also important that clinicians involved in a patient’s care work together and communicate well to provide joined-up treatment. 

Between 1 April 2021 and 31 March 2025, the Parliamentary and Health Service Ombudsman (PHSO) saw a 25% rise in complaints and a 65% rise in the number of investigations related to strokes. 

The Ombudsman has seen repeated failings in diagnosis, nursing care, communication, and treatment.

Rebecca Hilsenrath KC (Hon), Chief Executive Officer, Parliamentary and Health Service Ombudsman, said:

Over the past four years we have seen a significant rise in the number of complaints and investigations related to people who have suffered a stroke, including typical and atypical presentations. This is particularly concerning as early diagnosis is crucial in giving patients the best opportunity for successful treatment and recovery. 

 

“These investigations all represent instances where organisations involved have not identified a failing. It is important that the NHS operates in a learning culture and that when things go wrong clinicians recognise what has happened and put it right for those involved, as well as improve care and treatment for future patients.” 

PHSO recently carried out an investigation following the death of 86-year-old George Fawcett. His family complained to the Ombudsman after previously raising their concerns about George’s treatment with the University Hospital of North Durham and being unhappy with their response.

The great-grandfather-of-two from Spennymoor, County Durham died after suffering a spinal stroke which was not diagnosed for nine days. The Ombudsman found that with an earlier diagnosis he might have lived longer, potentially giving him and his family a few additional days together.

George, a former ambulance driver in the RAF, was admitted to the University Hospital of North Durham in May 2021. He was having chest pain, weakness in his legs and arms, and there had been a rapid decline in his mobility leading to paralysis.

An MRI was ordered but he was not immediately referred to the neurology department as he should have been. Then, after his scans were reviewed, he was wrongly referred to the orthopaedics department.

The orthopaedics team sent George back to neurology where doctors suspected he might have had a spinal stroke. 

Doctors should have referred him to a stroke unit within 24 hours but he was not seen by a stroke consultant until four days later. 

It was another three days before he was moved to a specialist unit at another hospital run by a different Trust. Clinicians there diagnosed him with a spinal stroke. 

George died two days later. His cause of death was heart failure and a heart attack, the secondary cause was a spinal stroke. 

While the Ombudsman found George’s death to be unavoidable, they concluded there were serious failings and his care fell below the standard expected. 

The PHSO investigation concluded that his stroke should have been diagnosed earlier than it was. Had this happened, he would have been moved to a specialist stroke centre earlier 

The Ombudsman also found that George was denied a dignified death as he developed pressure sores that weren’t treated properly at the University Hospital of North Durham.

PHSO recommended that the hospital Trust create an action plan to prevent this happening again and also apologise to George’s family and pay them a financial remedy. The Trust has agreed to comply.

George’s family initially complained to PHSO about other aspects of his care and were unaware until the Ombudsman began its investigation that he had suffered a stroke as early as he did and that doctors had failed to identify it.

George’s daughter, Sandra Todd, said:

The care my dad received was nowhere near the level it should have been and felt very fractured. We were raising concerns with the hospital all the time but no one would listen to us. That’s why we approached the Ombudsman, so that there could be an independent investigation into what happened and that’s how we finally learned the truth.

 

“My dad had some underlying health problems and had had a stroke 14 years earlier, but before he went to hospital he was independent, mobile, playing bowls several times a week, going shopping independently, and seeing his friends. 

 

“But the doctors at the hospital just seemed to dismiss him as an old man with mobility problems. They didn’t see what was really happening. Given his history of having a stroke before and his symptoms at the time, it was devastating to find out that they completely missed the signs. 

 

“We complained to the Ombudsman so that we could get justice for George and prevent this from happening again. We hope something positive will come from what the Ombudsman has found so that others don’t have to go through the same experience.”

Read the full investigation report.

The Ombudsman has written to the Chief Executive of the Northern Ireland Housing Executive to say she has commenced an 'own initiative' investigation into the organisation.

The decision follows the Ombudsman’s consideration of the Housing Executive’s response to her investigation proposal from earlier this year.

Click here for further details.

Paula Sussex has been appointed Parliamentary and Health Service Ombudsman (PHSO) by His Majesty King Charles.

Paula, a graduate of the London Business School and a trained barrister, will take up the role from 1 August 2025.

Arrangements are now in place, meaning all casework can progress as normal.

She joins PHSO from the financial technology firm OneID where she has been CEO since 2023.

Paula was CEO at the Student Loans Company from 2018 to 2022, and the Charity Commission, from 2014 to 2017.

She has extensive leadership experience, particularly in delivering major transformation and change programmes and services in the public, private and voluntary sectors.

She was awarded a CBE in 2022 for services to higher education.

Paula said:

“PHSO delivers an important service by both providing transparency and justice for people who have been let down by public service failings and also holding those responsible to account. It also has a unique opportunity to play an active role in the improvement of public service.

“A priority for me therefore as Ombudsman is to focus on the key themes where PHSO’s investigations and recommendations can have the greatest impact. By harnessing the insights we provide, we can help address underlying systemic challenges that affect many people who use public services.

“I am immensely honoured to be appointed as the new Ombudsman. I would like to thank Rebecca Hilsenrath for her excellent work as interim Ombudsman. I look forward to working together to build on the good work that has already been done, and to lead PHSO into the next chapter as we continue to strive for excellence.”

Rebecca Hilsenrath KC (Hon), Chief Executive of PHSO, said:

 “I am delighted that Paula has been appointed and look forward very much to working closely with her. I am confident that our new partnership, together with the rest of the team, will provide the right leadership to support those who have been let down by public services, while driving forward systemic changes for the benefit of all.”

The Local Government and Social Care Ombudsman is issuing practical guidance to housing officers to ensure Disabled people’s homes meet their needs.

Following on from the Ombudsman’s focus report on Disabled people and housing, the new Good Practice Guide is designed to help officers in local councils improve their practice when dealing with people who need housing adaptations, often through what are called ‘Disabled Facilities Grants’ (DFGs).

Alterations can include simple changes like handrails or ramps to extensive adaptations like internal lifts or extensions to create wheelchair-accessible bathrooms or extra living space.

The guide includes several case studies drawn Ombudsman investigations to illustrate the difficulties people have faced, and the solutions and remedies recommended by the Ombudsman to put the problems right.

Drawing on the Ombudsman’s extensive experience, the Guide also offers key learning points for officers, including:

• ensuring robust procedures set out expectations for all services involved in delivering DFGs, including timescales, to avoid delay
• communicating clearly and effectively with applicants
• keeping accurate and detailed records, particularly of the agreed works and amount of the grant awarded
• ensuring the completed works meet the assessed needs
• having regard to the additional guidance on DFGs for children

Ms Amerdeep Somal, Local Government and Social Care Ombudsman said:

“Disabled Facilities Grants can play an essential role in helping people remain in their homes for as long as possible with the best possible quality of life.

“They are often complex, not just because of extensive building work, but also the numerous organisations involved. So it’s essential that councils do all they can to avoid delay, and ensure any work is carried out to adequately meet people’s needs. When it does not, we know this can be extremely stressful for the people involved.

“We are issuing this guide – directly aimed at those officers who work with Disabled people in their homes – to help ensure local councils get things right.”

This month we published decision reports from 20 complaints investigated by the Ombudsman. Thirteen of these were about health services, six about local government and one about a water provider. The outcome of these 20 complaints were

• Fully upheld: 12
• Some upheld: 5
• Not upheld: 1
• Resolved: 2

We made 61 recommendations to public bodies.

Resolving a complaint 

This month, we closed two cases as resolved. These are examples of cases where positive outcomes can be achieved for the complainant without the need for a long or detailed investigation.

We actively seek opportunities to resolve complaints at all stages of our process.

Resolution improves customer experience by providing redress more quickly and helps to rebuild relationships with public bodies.

In one case, a complainant told us they wanted a backdated kinship care allowance as they were the kinship carer for their grandchild. There had been some confusion over which authority was responsible for managing this, as the grandchild had moved from a different area.

When we opened our investigation, we contacted the local authority and listed the outcomes the complainant was seeking. They agreed to award a backdated payment of over £17,000, apologise to the complainant and update their kinship care policy and procedure as a result of learning from this case. 

This is a significant outcome for the complainant, and we welcome the local authority’s commitment to resolution and willingness to engage in reflective learning.

Our published decision reports can be found on our website.

Resources

• Redress Policy 

  While we do not award compensation, we can recommend redress where a financial loss has occurred. However, such circumstances are often limited. 

• Good practice guidance: alternative complaint resolution approaches

  Check out our guidance for examples of when an investigation may not always be the best option.