Investigation Summaries

After an investigation is completed, we publicly share our findings and the recommendations we made to raise awareness of important issues and to encourage health organizations to learn from the experience. We do this by releasing either a full investigation report or an investigation summary. Investigation summaries allow Patient Ombudsman to publicly share the outcome of an investigation while protecting privacy and confidentiality of personal health information. 

Patient Ombudsman continues to follow-up with health sector organizations on their progress implementing these recommendations. 

Read more about our investigation work and ongoing investigations.

 

Investigation Reports and Summaries 

2025

• Home care medical supplies disruption (Report)

• Security use of force in the emergency department

• Poor communication contributed to pregnant patient leaving against medical advice

• Delay of secondary disclosure report

2024

• Failure to Communicate and Act on a Cancer Diagnosis

• Resident Experience of Palliative Care in Long-term Care Home

• Culturally safe and trauma-informed complaints management

• Discharge of vulnerable youth

• Managing a complaint of alleged abuse/neglect for home care client

2023

• Billing for uninsured services

• Chronic care co-payment

• Reprisal and access to care

2021

• Fair and transparent billing policies and practices

• Breakdown in coordinated care for a vulnerable patient

2018

• Lost personal property in hospitals