This month we published decision reports from 12 complaints investigated by the Ombudsman. Ten of these were about health services and two about local government. The outcome of these 12 complaints were
- Fully upheld: 6
- Some upheld: 2
- Not upheld: 4
We made 22 recommendations to public bodies.
Significant Adverse Event Reviews
Several of our cases this month relate to Significant Adverse Event Reviews (SAERS).
In one case, we found that a GP practice had not carried out the review in line with national guidance after a patient died following the discontinuation of their medication. We asked the practice to ensure SAERs are reflective and identify any appropriate learning and improvement to take forward.
In another case, a health board failed to carry out any internal review after not providing follow-up care to a patient after neurosurgery. In a third case, a board did not carry out a SAER after a patient suffered avoidable pressure injuries. In both cases, we asked the boards to ensure that statutory processes for learning are initiated when it becomes known that potential or actual harm has occurred.
These processes are essential for ensuring patient safety, promoting transparency, and supporting continuous learning.