Recommendation F118: Learning and information from complaints
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, refuses to agree, or for some other reason publication of an upheld, clinically related complaint is not possible, the summary should be shared confidentially with the Commissioner and the Care Quality Commission.
In brief (written by this site)
The Inquiry recommended that healthcare providers publish summaries of upheld patient care complaints on their websites. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the department had "not taken forward this recommendation as set out", pointing instead to statutory annual complaints reporting and decision summaries published by the Ombudsman (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in part in 2014 but had not explicitly addressed its planned reconsideration regarding serious complaints (The Thirlwall Inquiry legal team, May 2024).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 1 Oct 2026. The record below is the sources' own words.
About this summary
This recommendation applies across many organisations. The record reflects central policy activity; adoption in individual organisations may vary.
Government response
Accepted in part.
An open culture demands that information is available to service users, their families and carers to enable them to make informed choices about their healthcare.
Trusts currently have to publish an annual report on complaints handling. This report contains information on the number of complaints received, the number referred to the Health Service Ombudsman, and a summary of the subject matter of those complaints, any matters arising from them, and any matters where action has been taken (or will be taken) as a result of the complaint. These reports are sent to the commissioning body, and made available to anyone who requests one, but the Government believes we can go further.
Rt Hon Ann Clwyd MP and Professor Tricia Hart’s Review of the Handling of Complaints in NHS Hospitals recommends that:
• There should be Board- led scrutiny of complaints. All Boards and Chief Executives should receive monthly reports on complaints and the action taken, including an evaluation of the effectiveness of the action. These reports should be available to the Chief Inspector of Hospitals.
The Department of Health will ensure that each quarter every hospital publishes information on the complaints it has received. This will include:
• the number of complaints received, as a percentage of patient interventions in that period;
• the number of complaints the hospital has been informed have subsequently been referred to the Ombudsman; and
• lessons learned and improvements made as a result of complaints.
The Department of Health will work with NHS England and other key partners to determine the most effective mechanism through which to achieve these outcomes.The Chief Inspector and Care Quality Commission will require regular reporting of complaints from all providers to inform its surveillance and risk profiling regime. Care Quality Commission will naturally be particularly interested in complaints concerning death, serious injury or ‘near misses’ but will also want to harness information about other aspects of patient experience and concern which would be indicative of trust culture and performance. Care Quality Commission will be discussing with Monitor, Trust Development Authority and providers a proportionate and cost- effective means of doing so.
The Department would wish to reconsider this recommendation in relation to complaints of a serious nature, and making them available in a wider range of formats, once an agreed and consistent standard exists against which to judge the handling of an individual complaint. This would lead to more consistency in outcomes.
How this response relates to the recommendation
Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.
Blanket government agreement does not establish acceptance or delivery by each addressee. Some response passages cover groups of recommendations.
Scope of the government response
Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Delivery
DHSC and NHS England say partially delivered (27 February 2026)
DHSC have not taken forward this recommendation as set out. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 require each NHS organisation to prepare an annual report that includes how many complaints they have received, a summary of the subject areas raised and actions taken as a consequence of the complaints. Under regulation 18, this report must be made available to any person who requests it.
The Ombudsman makes final decisions on complaints about the NHS in England, UK Government departments, agencies and public bodies such as museums. These casework decisions date from April 2021 and are published two months after the case is closed. Summaries per case are published on the PHSO website.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Partially Implemented - Ongoing”. Table row: section 18.2 No. 118, PDF page 481.
Department of Health and Social Care says in progress (11 February 2015)
It is important for organisations to be accountable to the public for the way they handle complaints. The Department of Health, working with the Health and Social Care Information Centre, committed to developing a system that enabled Trusts to publish accurate, detailed quarterly data on the number of complaints received, and to enable comparison across hospitals. The overall aim of the revisions is to provide members of the public and regulatory bodies with frequent, more meaningful data which will identify organisations whose level of complaints, whether high or low, suggests there may be cause for concern. Hospitals will begin revised collections from April 2015, with the first quarterly report envisaged by late summer 2015. It is expected the public can begin to compare Trusts’ complaints data by late Autumn 2015.
The Department of Health is working with NHS England to strengthen the 15/16 NHS Standard contract so it includes the need to prominently display complaints information.
Sir Mike Richard’s thematic complaints report was published in December 2014. It covers acute inspections, primary care, and social care and identifies trends and themes in complaints handling drawn from the inspections done by the Care Quality Commission.
Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.
Site note: The Inquiry addressed this recommendation to healthcare providers, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was accepted in part by the Government.
In the January 2014 Hard Truths report, the Government said it wished to reconsider the recommendation in relation to complaints of a serious nature and making them available in a wider range of formats, once an agreed and consistent standard existed against which to judge the handling of an individual complaint.
The February 2015 Culture Change report did not explicitly address this planned reconsideration.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 118, PDF page 447.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding