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Patient Ombudsman 2023/24

Meeting the Call

Better Experiences
Better Health Care

Intersecting blue paths forming a pattern weave with a diverse group of people—children, adults, seniors—gathering over it, including individuals with assistive devices and support animals, and health care workers. The scene reflects inclusivity and accessibility, showcasing people of different ages, genders, and abilities.

Patient Ombudsman’s message

As one of the few ombuds offices in Canada focused exclusively on health care, Patient Ombudsman is uniquely placed to gather and share information and make recommendations to improve the quality of health care.

What Patient Ombudsman does

We champion fairness for everyone, and work to ensure more positive health care experiences for all Ontarians.

2023/24 at a glance

251 written complaints were open on April 1, 2023
4,429 new complaints received in 2023/24
1,499 new written complaints
2,930 new complaints to call centre
4,575 complaints resolved in 2023/24
1,630 written complaints
2,945 complaints to call centre
118 written complaints were open on March 31, 2024 and carried into 2024/25
  • Written complaints increased by 30%, while new complaints to the call centre were 9% lower than 2022/23.
  • 133 complaints involved two or more organizations or services.
  • More than 280 people submitted multiple complaints to Patient Ombudsman in 2023/24.

Year over year growth in complaints

Bar graph showing complaints from 2016 to 2024. While there was a slight dip in 2021/2022, complaints rose sharply in 2023/24, reaching a record high of 4,429.

Improving efficiency

In 2023/24, Patient Ombudsman resolved more complaints than it received, despite an overall growth in the number of complaints received.

The 1,630 written complaints resolved in 2022/23 included the remaining cases from a backlog that accumulated because of the COVID-19 pandemic. After the backlog was eliminated in July 2023, significant improvements have been made in our response time to written cases, as shown in the graph below. Most call centre complaints continue to be resolved within three days and written complaints are acknowledged in writing within days of receipt.

Flow chart comparison of written case processing times before and after August 2023. Prior to August 2023 (left side, blue box): 85% of written cases were assigned within 151 days and closed within 201 days. Since August 2023 (right side, green box): improvements were noted with 85% of written cases assigned within 49 days and closed within 81 days.

Spotlight issues

Deeper insights to guide better health care experience

Patient Ombudsman monitors the complaints we receive to identify emerging issues. Our “Spotlight” stories shine a light on the kinds of cases we receive, how we achieve resolutions, and where health sector organizations can look for opportunities to improve patient and caregiver experiences.

Spotlight 1/3: Community Surgical and Diagnostic Centres

On September 25, 2023, Patient Ombudsman’s mandate was expanded to include oversight of complaints about experiences with community surgical and diagnostic centres.

Read spotlight 1
An adult holds hands with a child who has a cast on their leg as they approach an employee at a front desk.

Spotlight 2/3: Patient and caregivers’ experiences with mental health care

Patient Ombudsman dealt with more than 400 complaints involving mental health and addictions services in 2023/24.

Read spotlight 2
A doctor puts their arm around a patient as a dog looks up at them.

Spotlight 3/3: Emerging concerns with obstetrical and gynecological care

In 2023/24, Patient Ombudsman began tracking an increasing number of complaints related to obstetrical and gynecological care issues, including complaints about insensitivity, poor communication and lack of responsive care for pregnancy complications, miscarriages, difficult births and sexual assaults.

Read spotlight 3
A doctor and a pregnant patient talk.

Circling back on issues highlighted in past reports

Health care workers assist an elderly woman as they move her in a wheeled hospital bed, with a family member standing nearby.

Follow-up 1 of 2:
Transitions of patients waiting for alternate levels of care

In September 2022, the Ontario government amended sections of the Fixing Long-Term Care Act, 2021 to expedite the transition of hospital patients deemed to be “alternate level of care” to long-term care homes.

Circling back on transitions
A health care worker denies access to a person walking in.

Follow-up 2 of 2:
Dealing fairly with no trespass orders and restrictions on access

One practice that hospitals, long-term care homes and other health care settings use is the issuing of “no trespass” notices to patients and visitors deemed to have exhibited inappropriate, aggressive or assaultive behaviour. While sometimes necessary to protect the safety of workers, patients and visitors, no trespass notices can have serious impacts by limiting people’s ability to enter a health care facility to access care or visit loved ones.

Circling back on trespass

Complaints data

Who we hear from and what we hear about

Who contacted Patient Ombudsman

Pie graph showing breakdown of individuals who submitted complaints: 53% Patients/Residents;16% Daughters/Sons of Patients; 7% Parents/Guardians; 6% Partners/Spouse; 6% Other Family Members; 3% Care/Service Providers; 2% Other; 8% Unknown.

How complaints were resolved in 2023/24

The path to resolutions

Patient Ombudsman closed 4,575 complaints in 2023/24 including 1,630 written complaints and 2,945 complaints received through the call centre.

Most of the complaints that Patient Ombudsman receives are resolved through the work of our Early Resolution Specialists – the frontline staff who work closely with both the person making the complaint and the health organization to learn what happened, to identify fairness issues, and to explore possible resolutions to address the concerns.

Early resolution of a written complaint often requires several conversations with the complainant, patient relations or other staff at the health organization to clarify concerns and any actions taken in response, and to assess the fairness of internal policies, processes, interactions, and outcomes. We may review health records, policies, procedures or surveillance video, or engage in research to help inform our analysis and assessments. When we close a written complaint, we provide the complainant and the health organization with a summary of our review and decisions. Call centre complaints are most frequently resolved by providing the complainant with information and referrals.

A summary of the actions taken and dispositions of these complaints is summarized in the chart below.

Results achieved through the resolution process

Flow chart summarizing 4,575 complaints that were closed. Of these, 369 complaints required further review and actions by Patient Ombudsman. The majority of the other complaints involve files where Patient Ombudsman directed and referred issues to appropriate contacts, including patient relations, other oversight bodies, regulatory colleges, and other services. Complaints were received through both the call centre (2,945) and written submissions (1,630).
Flow chart summarizing 4,575 complaints that were closed. Of these, 369 complaints required further review and actions by Patient Ombudsman. The majority of the other complaints involve files where Patient Ombudsman directed and referred issues to appropriate contacts, including patient relations, other oversight bodies, regulatory colleges, and other services. Complaints were received through both the call centre (2,945) and written submissions (1,630).

Patient Ombudsman actions

Here are the outcomes achieved
261 researched options and solutions
54 participated in meetings/case conferences
24 facilitated meetings/case conferences
369 courtesy calls to patient relations were made on behalf of complainants
129 requested and reviewed records
31 made suggestions to health sector organization
23 mandatory reports made to the Ministry of Long-Term Care

Health sector organization actions to improve patient experiences

85 met expectations
60 provided service
35 provided staff education/training
12 revised policies/procedures
63 acknowledged negative experience
39 provided an apology
31 acted on Patient Ombudsman suggestions
4 waived or adjusted fees

Helping people get to the right place to address their concerns

Complaining about negative experiences with health care can be as complicated as the health care system itself.

While the health sector organizations within Patient Ombudsman’s jurisdiction are required to have internal complaints processes, people often don’t know where to start and often come to Patient Ombudsman before they’ve attempted to address their concerns directly with the health organization. Based on the nature and complexity of the complaint, different parts of the complaint may fall to different organizations in addition to Patient Ombudsman. For example, complaints about the conduct, competence and capacity of health care professionals fall within the jurisdiction of their regulatory colleges. For many health service providers, such as community mental health and addiction services, there is no agency or body that provides independent oversight of complaints for issues that do not fall under the jurisdiction of the regulatory colleges.

When Patient Ombudsman lacks the authority to look into a patient’s or caregiver’s concerns, our team helps people connect with an organization or individual who can help. In helping to resolve 4,575 complaints in 2023/24, Patient Ombudsman provided navigation assistance to 3,720 patients and caregivers. This included making more than 6,000 referrals to address aspects of their concerns and more than 350 courtesy calls to enable warm handovers to other individuals or bodies.

2023/24 Most frequent referrals

Graph showing the breakdown of referrals in 2023/24. The highest number were to internal complaints processes (3,056), followed by referrals to health professions regulatory colleges (1,721). Other notable categories include referrals to oversight bodies (432), health and other services (322), provincial government ministries or members of provincial parliament (320), and other referrals (266).

Investigations

Deeper insights for system change

In 2023/24, Patient Ombudsman completed two investigations and at the end of fiscal 2023/24, four investigations were underway.

Investigations generally occur when an early resolution to a complaint cannot be achieved, there are disputes about the facts, or through Patient Ombudsman’s own initiative when there is a systemic issue or a matter of high public interest that comes to our attention through trends in complaints, media reports or third parties.

Management of a complaint about alleged abuse/neglect of a home care client

Patient Ombudsman investigated a complaint from a family member of a home care client concerned that Home and Community Care Support Services (HCCSS) did not address complaints that their parent was subject to abuse and neglect while receiving services.

Discharge of a vulnerable youth

Patient Ombudsman investigated a complaint about the discharge process for a vulnerable youth from a pediatric mental health unit of a large teaching hospital.

Complaints about Patient Ombudsman’s services

Feedback helps us improve

Complaints provide important information about opportunities to improve the health care experience of patients, residents and caregivers.

Patient Ombudsman strongly believes that this applies not only to health sector organizations, but also to our own work and we welcome feedback about our processes and resolutions. Concerns that cannot be addressed directly by our early resolutions specialists and investigators are escalated to management for review. These concerns are documented and monitored in Patient Ombudsman’s complaint management system and each is assessed to determine if we met our service standards and ombuds standards and if the outcomes were reasonable based on the nature of the complaints. If complainants are unsatisfied with our review, we provide them with information about escalating their concern to the Ontario Ombudsman, which has oversight of Patient Ombudsman.

In 2023/24, Patient Ombudsman received 17 complaints from patients, residents or caregivers that required escalation and two from the Ontario Ombudsman.

Subject of complaint about Patient Ombudsman

  • Resolution achieved : 15
  • Patient Ombudsman assessment report : 3
  • Communication : 2
  • Technology : 2
  • Service provided : 1

Decision arising from management review

  • No evidence of service failure : 9
  • Partially upheld : 7
  • Fully upheld : 2
  • No decision
    (complaint withdrawn) :     1

Actions taken by Patient Ombudsman

  • No action required : 10
  • Apology : 5
  • Feedback given to staff : 3
  • Case re-opened : 2
  • Explanation provided : 2

Note: Complaints can involve more than one subject and/or action

Summary

Final Thoughts

When it comes to supporting patients, residents and caregivers in making complaints, every day and every complaint is different.

That’s part of what makes ombuds work so interesting and valuable, and what drives the Patient Ombudsman team to meet the growing demands for the office’s services.

Over 2023/24, the team achieved some significant milestones that highlight our commitment to supporting complaint resolution and ensuring better health care experiences for everyone. This report showcases much of significant accomplishments achieved including eliminating the backlog of complaints that arose during the pandemic, creating efficiencies to reduce the time to case assignment, adapting to manage a 30% growth in written complaints, and initiating more investigations than ever before.

We’re also continuing to work to advance our data collection so that we can refine the stories we share and better highlight the situations facing the health care system, such as our spotlight on mental health.

With our newly released Strategic Plan in hand to guide the coming three years, we know we’ll continue improving our processes and growing to meet the needs of Ontarians.

Download our full report