The investigation also found that people do not complain as they do not believe it would make any difference. The report of the investigation, Learning to Get Better, was published today, Wednesday 27 May. The Ombudsman carried out the investigation as he was concerned that his Office was receiving very few complaints about the healthcare system compared with Ombudsman offices in other countries.
Speaking at a seminar to launch the report the Ombudsman said:
"Complaints are a vital early warning system for hospitals and other health services. I wonder if the tragic events seen in Áras Attracta and the Midlands Hospital Portlaoise, could have been avoided if those complaints that were made were dealt with properly."
The seminar was also addressed by Sir Robert Francis, author of the seminal report into the failures at the Mid Staffordshire NHS Trust in the UK, and by Tony O'Brien, Director General of the HSE, who set out how the HSE intends to improve complaint handling in public hospitals.
The Ombudsman has recommended that the HSE and each hospital put an action plan in place to:
The Office of the Ombudsman will be monitoring the implementation of the action plans to ensure that improvement is achieved and sustained. The report follows an extensive investigation by the Ombudsman's Office which listened to the public, hospital staff, representative groups, and involved site visits to a selection of hospitals.
Today's seminar was attended by representatives of the HSE, the Department of Health, health groups, and almost all hospital groups and major hospitals.
The Ombudsman's report, 'Learning to Get Better - How Public Hospitals Handle Complaints' is available on the Ombudsman's website.
'Learning to Get Better' is the first 'own initiative' investigation by the Ombudsman since the Office was established over 30 years ago. Complaints to the Ombudsman about healthcare represent 20% of all complaints received. This is very low compared with other jurisdictions such as Northern Ireland (over 60% investigated) and the UK Parliamentary and Health Services Ombudsman (80%).
The Ombudsman set out to find out why. The investigation was the most extensive investigation carried out by the Office and involved surveys of all public hospitals, site visits to a sample of hospitals, interviews with front line and senior hospital staff, focus groups with members of the public, consultations with health sector and advocacy groups, and a review of complaints dealt with by some hospitals.
The investigation discovered that many users of hospital services:
As a result, the Ombudsman has made a number of recommendations, and has asked the HSE and each of the voluntary hospitals, to develop an action plan in order to monitor the implementation of his recommendations.