PHSO Systemic Investigations
Tracking 22 recommendations across 4 systemic investigation reports from the Parliamentary and Health Service Ombudsman (2017–2024). Source: ombudsman.org.uk.
4
Investigations
22
Recommendations
4
Accepted
3
Rejected
7
Pending
Key Insights
55% acceptance rate — of 22 recommendations, 4 were accepted and 8 partially accepted.
3 were rejected outright.
77% have government responses — 17 of 22 recommendations received a formal response from addressees.
1 Section 10(3) report — these rare reports are laid before Parliament when organisations refuse to comply with PHSO recommendations.
Top addressees:
Department for Work and Pensions, HM Government, Department of Health and Social Care / NHS England, Department of Health and Social Care, NHS England.
Women's State Pension age: our findings on injustice and associated issues
Section 10(3) Special Report
Partially Accepted
Investigation into DWP's communication of state pension age changes to women born in the 1950s. Found maladministration in a 28-month delay in writing to affected women. Laid before Parliament under s10(3) because PHSO anticipated DWP would not comply. Government rejected compensation recommendations twice (Dec 2024, Jan 2026) but accepted the apology and some service improvements.
Compliance:
Not Complied
Discharge from mental health care: making it safe and patient-centred
Systemic Investigation
Partially Accepted
Systemic investigation into unsafe discharge from mental health settings. Based on PHSO casework showing patients being discharged without adequate follow-up, safety planning or family involvement. Makes 5 recommendations covering statutory guidance implementation, 72-hour follow-up extension, nominated person involvement, and the Mental Health Bill.
Compliance:
Partially Complied
Broken trust: making patient safety more than just a promise
Systemic Investigation
Partially Accepted
Systemic investigation into patient safety failings across the NHS, examining how the patient safety system fails to learn from mistakes. Draws on PHSO casework to identify failures in local investigations, duty of candour, patient advocacy, and oversight. Makes 7 recommendations to DHSC, NHS England, ICBs and government.
Compliance:
Partially Complied
Ignoring the alarms: How NHS eating disorder services are failing patients
Systemic Investigation
Partially Accepted
Systemic investigation into NHS eating disorder services, finding patients failed by inadequate training, poor transition from child to adult services, lack of coordination and insufficient specialist provision. PACAC follow-up (2019) found 'not enough action' taken. PHSO wrote to ministers again in March 2024 calling for eating disorder care to be made a priority.
Compliance:
Not Complied