Today the Parliamentary and Health Service Ombudsman publishes its first annual Ombudsman’s Casework Report. The Report shows the wide range of cases the organisation concluded in 2019. As well as serious complaints about the NHS in England, the report includes cases involving UK government departments and other public services.

The variety of complaints in the report, from delays in receiving child maintenance payments to sea bass fishing licences, show that public service failures affect people from all walks of life. Yet complaints about government bodies account for a small proportion of the complaints brought to the Ombudsman. This is partly due to outdated legislation that prevents people from accessing the service directly, as they have to refer their complaint to an MP first. 

Ombudsman Rob Behrens said:

‘What connects the varied cases in this report is that something has gone wrong with a public service. When people bring such cases to us we hold organisations to account – making sure they learn from mistakes so they are not repeated.

‘We hope that, as is the case for the NHS, complaints about the UK Government and its agencies can soon come to us directly rather than needing referral by an MP. The legislation governing this is outdated and should be changed swiftly.’

The Ombudsman’s longstanding call to remove the barrier to direct access is supported by all of PHSO’s fellow UK public service ombudsmen.

Public Services Ombudsman for Wales, Nick Bennett, said:

‘The requirement to complain to an MP first is an outdated barrier. It is not acceptable that the Ombudsman’s office is not directly accessible to the people who need it most. Providing a voice for the voiceless is essential for a modern-day Ombudsman.

‘I fully support the proposals to reform the PHSO legislation to remove the MP filter, bringing it in line with my office and other UK public service Ombudsmen.’

A wide range of complaints

In one of its cases about UK Government agencies, the Ombudsman found that a single mother missed out on years of child maintenance because of failings by the Child Support Agency (CSA). The Ombudsman found the Agency missed vital opportunities to ensure that arrears totalling more than £10,000 were paid.

There are two complaints about the Marine Management Organisation (MMO), whose failings led to loss of livelihood for two fishermen. In one case, the MMO mistakenly told the complainant that the boat he bought was licenced to fish sea bass. The boat did not have the appropriate licence, meaning the complainant was unable to use their newly purchased boat to fish, which had a negative impact on their income.

A complaint about Ofgem shows how the Ombudsman resolved some complaints without the need for a full investigation. A supplier installed a renewable heating system in the complainant’s home which meant they were eligible for payments through the government’s Domestic Renewable Heat Incentive (RHI). The supplier made a paperwork error which led to Ofgem not approving the system under the scheme and asking the complainant to repay almost £20,000. The Ombudsman asked Ofgem to review the case, it recognised the error that had been made, and it was resolved for the complainant.

The report also highlights more cases about poor communication and delays with licencing decisions by the Driver and Vehicle Licensing Agency (DVLA). These issues were raised in the Ombudsman’s 2016 report, Driven To Despair, and these cases show that similar failings continue to impact on people’s lives.

NHS Trust’s failings led to tragic consequences

The Ombudsman also continues to see complaints about serious failings in NHS care, which are highlighted in this first annual casework report.

He has highlighted in the report the tragic case of Catherine Gould, a grandmother who died because she was not given her regular insulin dose at Great Western Hospitals NHS Foundation Trust.

Catherine was admitted to the Trust following a fall, but when she was transferred from one ward to another she was not given her vital nightly insulin injection. Two days later Catherine developed diabetic ketoacidosis (DKA), a life-threatening condition that occurs in people with diabetes when they are low on insulin and causes the body to produce dangerous levels of blood acids. Staff successfully treated her for DKA, but she continued to deteriorate and two days later, Catherine suffered a heart attack and died.

Catherine’s daughter, Ali Gould, said:

‘Mum knew a mistake had been made and didn’t want to get anyone into trouble, but she did want to make sure this never happened to anyone else.

‘To make sure of this, the Trust must acknowledge that their mistake, due to their poor record keeping, communication and lack of diabetic knowledge, contributed to Mum's untimely death.’

The Trust has since acknowledged that it was at fault and following the Ombudsman’s recommendations has put in place an action plan to make sure the failings are not repeated.

Read the Ombudsman's Casework Report