Stop animation

Patient Ombudsman 2024/25

Listening
Learning
Leading
change

Better Experiences
Better Health Care

Patient Ombudsman’s message

“Throughout the year, I speak to many groups about the types of complaints we receive, the resolutions we achieve, and the recommendations we’ve made to address systemic issues through our investigations.”

What Patient Ombudsman does

Patient Ombudsman’s role is to help resolve complaints from patients, long-term care home residents and caregivers about health care experiences in an independent and impartial manner.

2024/25 at a glance

264 open cases carried over from 2023/24

4,886 new cases received in 2024/25

4,863 cases closed in 2024/25

306 open written cases carried over to 2025/26

The office received a total of 4,886 new complaints in 2024/25 (April 1, 2024, to March 31, 2025), 1,734 written cases and 3,152 complaints to the call centre. This represents a 16% increase in new written complaints over 2023/24 and an 8% increase in new complaints to the call centre.

New complaints to Patient Ombudsman by year

Bar graph showing the year-over-year growth in complaints at Patient Ombudsman from 2016 to 2025. There is an overall trend of increasing complaints, up to year 2024/25 which had the most complaints to date (4,886).

Patient Ombudsman resolved 1,692 written complaints in 2024/25, 4% more cases than 2023/24, but fewer than the number of new cases received. As a result, 306 open cases were carried over into 2025/26.

Patient Ombudsman closed 3,171 complaints to the call centre in 2024/25, an 8% increase over 2023/24. The majority of complaints to the call centre (85%) were resolved within four days, and the exceptions were most frequently because of challenges contacting the complainant to provide new information or respond to complaints left by voicemail.

Spotlight issues

Insights to Guide Better Health Care Experiences

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.

Illustration of three speech bubbles, each with different people inside them. Centre: two people chatting while one writes on a pad. Top right: person in a wheelchair looking to the left. Bottom left: Person with headset looking to the right.

Illustration of two speech bubbles, each with different people inside them. Top: Pregnant woman looking down with one hand on her belly and the other over her face, with a medical professional touching her arm. Bottom: Mother holding and looking down at her baby with a smile.

Illustration of two speech bubbles, each with different people inside them. Top: nurse wearing a mask pushing a hospital bed. Bottom: two people seated as if in a waiting room. One is wearing a neck brace; the other is frowning.

Illustration of speech bubble showing a doctor gesturing to a laptop while talking to two smiling people.

Illustration of speech bubble showing a medical professional taking notes and a person talking to a person lying in a hospital bed.

Patient Ombudsman Investigations

In 2024/25, Patient Ombudsman completed six investigations and had two additional investigations underway at the end of our fiscal year in March 2025.

Investigations generally come about one of two ways: through a complaint made to our office that cannot be resolved at the early resolution stage or through Patient Ombudsman’s own initiative when a systemic issue or matter of public interest comes to the office’s attention through complaint trends, media reports or third-party reports.

The investigations completed in 2024/25 touched on a variety of topics and represent more than 40 recommendations to health care organizations.

May 2024

Oct 2024

Dec 2024

Jan 2025

Feb 2025

Following through on recommendations

Since the office opened in 2016, Patient Ombudsman has carried out 14 investigations resulting in 99 recommendations to health care organizations. Investigation summaries, including recommendations, are available on our website.

In 2024/25, we formalized a tracking tool to better understand the progress organizations have made on implementing our recommendations. To date, 47% of recommendations are fully implemented and 44% are in progress. Some recommendations require significant time and resources before being fully implemented – for example when organizations have to roll out staff training or restructure processes.

Reporting on these outcomes provides ongoing transparency and a quick “at-a-glance” view of how health care organizations are moving forward with implementing changes.

Investigations Recommendation Actions 2018-2025

Stacked bar graph showing the number of investigations per topic between 2018 and 2025 categorized by status: Fully implemented, unable to implement, no actions taken, and pending.

Text description of graph, “Investigations Recommendation Actions 2018-2025”

Complaints data

Who we hear from and what we hear about

Who contacted Patient Ombudsman

Pie chart showing breakdown: 54% Patient/resident; 17% Daughter/son of patient; 7% Partner/spouse; 7% Parent/guardian; 5% Other family member; 5% Other; 6% Unknown

As in prior years, complaints about public hospitals were disproportionately high in the Toronto region and suggest that the Toronto region complaints are augmented by people from surrounding communities who received care in Toronto hospitals. Complaints about long-term care homes, and home and community care are highest in the North region and may reflect the human resources and geographic challenges of providing care in smaller population centres in a vast geography.

This year, Patient Ombudsman matched the postal codes from complainants with the Ontario Health regions to review where complainants are located.

As shown in the chart, “Written complaints per 100,000 people in each Ontario Health region”, the geographic profile based on the location of complainants varies somewhat from the profile of the health care organizations named in complaints. This supports the theory that the number of complaints about Toronto health care organizations is affected by people from other communities who come to Toronto for care. In both profiles, complaints about health care in the North region are higher than the rest of the province.

Written complaints per 100,000 people in each Ontario Health region

Location of health care organizations

Bar graph showing breakdown: 9 for Toronto, 13 for North, 9 for West, 8 for East, and 7 for Central.

Location of complainants

Bar graph showing breakdown: 21 for Toronto, 19 for North, 12 for West, 11 for East, and 8 for Central.

Complaints about public hospitals made up a slightly larger proportion of the new complaints in 2024/25 compared to past years, and complaints about services outside Patient Ombudsman’s jurisdiction made up a smaller proportion of new complaints. Just over 4% of new complaints (call centre and written) involved two or more health settings.

Public hospitals: 57% of complaints

Pie chart highlights the 57% of complaints that are for public hospitals.

As in previous years, more than half of the complaints Patient Ombudsman handled in 2024/25 involved public hospitals.

Overall quality of care in hospitals continues to be the concern expressed most frequently by patients and their caregivers. Complaints about hospital discharges, transitions and transfers increased this year, and this issue is explored in greater depth in Spotlight Issue #4. In addition to concerns related to long-term care home placement from hospitals, these complaints also related to transitional care units, access to inpatient rehabilitation prior to discharge, inability to transfer between hospitals and coordinated discharge planning.

Effective, compassionate communication is an underlying factor in the vast majority of complaints, and specific concerns about sensitivity, caring, courtesy and respect was a top five concern again this year.

New complaints in 2024/25

Call centre : 1,548
Written complaints : 1,233

Top complaints

# 1 Quality of care : 29%
# 2 Discharge/transfers/transitions : 13%
# 3 Diagnosis/treatment : 13%
# 4 Sensitivity/caring/courtesy/respect : 9%
# 5 Patient/resident information/records : 5%

Emerging and persistent themes

Care in emergency departments

Mental health and addictions

Discharge and transition planning for complex patients, including 175 complaints involving long-term care home placement from hospital

Long-term care homes: 7% of complaints

Pie chart highlights the 7% of complaints that are for long-term care homes.

Seven per cent of complaints included concerns about long-term care homes, with overall quality of care being the most frequent concern.

Complaints about abuse/assault involved reports of abuse by both long-term care home staff members and other residents. In 2024/25, Patient Ombudsman made 25 reports to the Ministry of Long-Term Care about incidents that resulted in harm or posed a risk of harm to residents, as required by the Fixing Long-Term Care Act, 2021. Patient Ombudsman has recently begun monitoring complaints about people being denied admission and readmission to long-term care homes because of their history of responsive behaviours related to dementia. Patient Ombudsman is also monitoring concerns related to falls and skin integrity/wounds.

New complaints in 2024/25

Call centre : 243
Written complaints : 109

Top complaints

# 1 Quality of care : 37%
# 2 Communication : 8%
# 3 Abuse/assault : 6%
# 4 Discharge/transfers/transitions : 5%
# 5 Personal security or safety : 5%

Emerging and persistent themes

Falls and falls prevention

Bed sores and wound care

Supporting residents with responsive behaviours

Home and Community Care Support services: 7% of complaints

Pie chart highlights the 7% of complaints that are for home and community care.

Complaints about home and community care services continued to make up less than 10% of all complaints in 2024/25, although this may under-represent the number of complaints involving home and community care. A significant number of hospital complaints about long-term care home placement (144) did not specifically name Ontario Health atHome, Ontario’s long-term care home placement coordinator. Ninety-seven per cent of the complaints about home and community care were about services provided through Ontario Health atHome, and 3% were about other home and community care providers within Patient Ombudsman’s jurisdiction.

As in prior years, the most common concerns were about care coordination and continuity, most frequently related to personal support services. These complaints involved concerns about missed care and Ontario Health atHome’s inability to fully and consistently staff patients’ care plans. Complaints expressing concerns about discharge, transfers or transitions most often involved concerns about home and community care’s roles in coordinated discharges from hospital to the community.

There was a spike in complaints in October 2024 about problems with the delivery and quality of medical supplies and equipment after Ontario Health atHome implemented new vendor contracts in late September 2024. The number of complaints decreased once mitigation strategies were put in place. Patient Ombudsman’s investigation of this issue will be completed in 2025/26.

New complaints in 2024/25

Call centre : 256
Written complaints : 104

Top complaints

# 1 Coordination/continuity : 20%
# 2 Quality of care : 17%
# 3 Discharge/transfers/transitions : 12%
# 4 Access or admission : 10%
# 5 Communication : 9%

Emerging and persistent themes

Personal support services

Long-term care home placement

Medical supplies and equipment

Community surgical and diagnostic centres: 4% of complaints

Pie chart highlights the 4% of complaints that are for community surgical and diagnostic centres.

Patient Ombudsman’s jurisdiction was expanded in September 2023 to include community surgical and diagnostic centres (also called Integrated Community Health Service Centres). In this first full year of reporting, 4% of the complaints to Patient Ombudsman involved these centres.

The centres are licensed by the Ministry of Health to provide a range of services including diagnostic imaging, sleep studies, midwifery services, abortion care and minimally invasive surgeries, among others.¹ The complaints to Patient Ombudsman in 2024/25 most frequently involved concerns about ultrasounds, X-rays, eye surgeries and sleep studies. Issues with communication and delays, particularly in relation to test results were the most frequently reported concerns. A number of people also reported concerns about sensitivity, caring courtesy and respect, including rudeness and a lack of respect for patient’s privacy and dignity. Complaints about fees were largely about the need to pay to access test results and records through a third-party provider. Some patients reported feeling pressured to pay privately for upgraded services or more rapid access rather than receive or wait for services fully funded by the Ontario Health Insurance Plan. Most of these complaints were related to eye surgeries. Complainants also reported challenges with making complaints to the centres.

¹ A list of the centres and the services they are licensed to provide is available on the Ministry of Health’s website at https://www.ontario.ca/page/community-surgical-and-diagnostic-centres

New complaints in 2024/25

Call centre : 87
Written complaints : 80

Top complaints

# 1 Communication : 31%
# 2 Delay : 27%
# 3 Sensitivity/caring/courtesy/respect : 20%
# 4 Fees : 12%
# 5 Complaints process : 12%

Emerging and persistent themes

Communication of test results

Difficult contacting centres/lack of response

Wait times

Health services outside of Patient Ombudsman’s jurisdiction: 25% of complaints

Pie chart highlights the 25% of complaints that fall under the category of “Health services outside of Patient Ombudsman’s jurisdiction”.

As in prior years, Patient Ombudsman received a significant number of complaints about programs, services or providers that are outside our jurisdiction. These complaints may be part of a complaint that includes a health care organization within Patient Ombudsman’s jurisdiction. For example, the patient may have a complaint about a hospital that includes concerns about ambulance services or a family physician. It’s also not unusual for people to come to Patient Ombudsman with concerns that don’t include any services within our jurisdiction.

Complaints about physicians or their practices account for 70% of the complaints about non-jurisdictional programs and services, and most of these were about problems with primary care. Patients reported challenges with finding a physician, being denied service, early office closures, difficulty accessing health information/records, problems contacting practices by phone and rude or insensitive communication from office staff.

Patient Ombudsman believes that ‘no door is the wrong door,’ and when we cannot directly assist to resolve a concern, every effort is made to help the complainant connect with an oversight body or individual that can help them. In 2024/25 Patient Ombudsman provided more than 2,900 referrals to other organizations and bodies, including more than 1,200 referrals to the College of Physicians and Surgeons of Ontario and 314 referrals to other health professions regulatory colleges.

New complaints in 2024/25

Call centre : 917
Written complaints : 328

Top complaints

# 1 Physicians and physician practices : 70%
# 2 Other Ministry of Health programs/services : 9%
# 3 Retirement homes : 3%
# 4 Programs and services funded by other government ministries : 3%
# 5 Other health care practitioners (e.g., nurses) : 2%

Emerging and persistent themes

Access to primary care

Access to specialist physicians

Laboratory and diagnostic services

Public hospitals: 53% of complaints

Pie graph highlights the 53% of complaints that are for public hospitals.

2022/23

50%

2023/24

53%

Top complaints

# 1 Quality of care : 29%
# 2 Diagnosis/treatment : 13%
# 3 Sensitivity/caring/courtesy/respect : 9%
# 4 Discharge/transfers/transitions : 9%
# 5 Patient/resident information/records : 5%

Complaints frequently involved more than one subject

As in previous years, more than half of the complaints Patient Ombudsman received in 2023/24 involved public hospitals.

Concerns about the overall quality of care in hospitals increased by more than 10% over last year and for the first time, complaints about sensitivity, caring, courtesy and respect were in the top three complaint subjects. Almost one in five complaints about public hospitals described concerns about patient and caregiver experiences in emergency departments and 15% involved concerns about mental health and addiction services. These complaints are examined in more depth in Spotlight Issue #2.

Long-term care homes: 8% of complaints

Pie graph highlights the 8% of complaints that are for long-term care homes.

2023/23

2023/24

Top complaints

# 1 Quality of care : 37%
# 2 Communication : 8%
# 3 Abuse/assault : 6%
# 4 Discharge/transfers/transitions : 5%
# 5 Personal security or safety : 5%

Complaints frequently involved more than one subject

Eight per cent of complaints included concerns about long-term care homes and the number of complaints (365) represented a 9% increase over 2022/23.

As in prior years, concerns about the overall quality of care was the most frequently reported issue. Complaints about restrictions to visitation decreased in 2023/24. Overall, across all sectors only 52 complaints included concerns specifically attributed to COVID-19. Complaints expressing concerns about abuse/assault or personal safety often reflected issues related to the behaviour of other long-term care home residents.

Home and Community Care Support services: 6% of complaints

Pie graph highlights the 6% of complaints that are for home and community care.

2022/23

2023/24

Top complaints

# 1 Coordination/continuity : 20%
# 2 Quality of care : 17%
# 3 Discharge/transfers/transitions : 12%
# 4 Access or admission : 10%
# 5 Communication : 9%

Complaints frequently involved more than one subject

Complaints involving home and community care services decreased slightly in 2023/24.

As in prior years, the most frequent concerns were about care coordination and continuity, and there was a slight increase in complaints involving the overall quality of care. Complaints involving concerns about discharge, transfers or transitions most frequently involved concerns about home and community care’s roles in discharges from hospital to the community. Almost one-quarter of complaints about home and community care were about the sector’s coordination of long-term care home placement. Concerns involving long-term care home placement from hospital are explored in greater depth in Follow-up Issue #1.

Community surgical and diagnostic centres: 2% of complaints

Pie graph highlights the 2% of complaints that are for community surgical and diagnostic centres.

Top complaints

# 1 Communication : 24%
# 2 Delay : 9%
# 3 Sensitivity/caring/courtesy/respect : 9%
# 4 Access or admission : 8%
# 5 Coordination/continuity : 8%

Complaints frequently involved more than one subject

Patient Ombudsman’s jurisdiction was expanded in late September 2023 to include community surgical and diagnostic centres. Complaints about these centres made up 2% of the complaints received. These complaints are considered in Spotlight Issue #1.

Other: 31% of complaints

Pie graph highlights the 31% of complaints that fall under the category of “other health care”.

In 2023/24, approximately one-third of new complaints included programs and services that are not within Patient Ombudsman’s jurisdiction either as the sole concern or in addition to concerns about health organizations within our jurisdiction. Complaints about doctors or their practices account for three-quarters of the complaints about non-jurisdictional programs and services, and most of these (78%) were about problems with primary care, including access to primary care, and a growing number about walk-in clinics. Patients reported challenges with denial of service, early closures, difficulty accessing health information/records, problems contacting practices by phone and rude or insensitive communication from office staff.

Public hospitals: 50% of complaints

Pie graph highlights the 50% of complaints that are for public hospitals.

2021/22

61%

2022/23

50%

Top complaints

# 1 Quality of care : 17%
# 2 Diagnosis/treatment : 16%
# 3 Discharge/transfers/transition : 12%
# 4 Communication : 9%
# 5 Sensitivity/caring/courtesy/respect : 8%

Complaints frequently involved more than one subject

Long-term care homes: 7% of complaints

Pie graph highlights the 7% of complaints that are for long-term care homes.

2021/22

10%

2022/23

Top complaints

# 1 Quality of care : 23%
# 2 Visitation/support person : 12%
# 3 Personal security/safety : 10%
# 4 Communication : 7%
# 5 Alleged abuse/assault : 6%

Complaints frequently involved more than one subject

Home and Community Care Support services: 6% of complaints

2021/22

2022/23

Top complaints

# 1 Staffing/resources/services : 18%
# 2 Access or admission : 18%
# 3 Coordination/continuity : 18%
# 4 Quality of care : 14%
# 5 Communication : 9%

Complaints frequently involved more than one subject

Other: 37% of complaints

Pie graph highlights the 37% of complaints that fall under the category of “other health care”.

2021/22

22%

2022/23

37%

Most frequent out-of-jurisdiction programs and services included in 2022/23 complaints

# 1 Medical care/medical practices : 1,081
Primary care : 785
Specialist care : 243
Unspecified : 53
# 2 Ministry of Health
(Ontario Health Insurance Plan (OHIP),
drugs and devices) : 76
Ministry of Long-Term Care
(Action line and Inspections Program) : 24
# 3 Programs/services funded by other ministries : 69
# 4 Ontario Health-funded community services : 42
# 5 Private hospitals/Independent Health Facilities : 39

Hospitals: 61% of complaints

Pie graph highlights the 61% of complaints that are for Hospitals.

Top complaints

# 1 Quality of care : 17%
# 2 Diagnosis/Treatment : 13%
# 3 Discharge/Transfer/Transition : 11%
# 4 Visitation : 10%
# 5 Access or delay : 8%

Complaints about sensitivity, caring, courtesy and respect increased by 43% over 2020/21.

Long-term care homes: 10% of complaints

Pie graph highlights the 10% of complaints that are for long-term care homes

Top complaints

# 1 Quality of care : 24%
# 2 Visitation : 19%
# 3 Communication : 12%
# 4 Personal security/safety : 6%
# 5 Finance/cost : 6%

Home and Community Care: 7% of complaints

Pie graph highlights the 7% of complaints that are for home and community care.

Top complaints

# 1 Access or delay : 25%
# 2 Staffing/resources : 20%
# 3 Coordination/continuity of care : 16%
# 4 Quality of care : 12%
# 5 Communication : 10%

19% of complaints about home and community care were about long-term care home placement processes, which is managed by Home and Community Care Support Services.

Other: 22% of complaints

Pie graph highlights the 22% of complaints that fall under the category of “other health care”.

More than 20% of complaints involved health services that are outside of Patient Ombudsman’s defined jurisdiction. Some of these complaints could be referred to a regulatory college or other complaints body that had jurisdiction over the issues described.

Improving our efficiency and effectiveness

In 2024/25, Patient Ombudsman implemented a triage process to improve how quickly we assign written complaints.

We review written complaints when they come to our office to determine if the concerns are within our jurisdiction, if the health care organization has had an opportunity to address the concerns directly and to assess the level of risk or urgency of the concerns.

Text description of flowchart, “Improving our efficiency and effectiveness”

Summary

Final Thoughts

This past year has been an important one of reflection for our office. Nine years represents a significant amount of work and data that shines a light on Ontarian’s health experiences and real opportunities for growth and change within the health system.

As this report shows, the Patient Ombudsman team continues to respond to growing numbers of complainants that reach out to our office and has improved its processes so that we can address a greater number of investigation issues and provide health care organizations with a greater number of recommendations to help improve patient, long-term care resident and caregiver experiences.

When working to resolve a complaint, ombuds focus on fairness and the actions a health care organization did or didn’t take to address patient and resident concerns. This means that patients and residents can sometimes have negative experiences, even if a review finds the health care organization acted fairly and reasonably in following policy. As this report outlines, many of our resolutions and recommendations are related to communication: acknowledgements, apologies, providing information in a timely way, increasing transparency, and ensuring trauma-informed approaches. Clear, compassionate communication can sometimes make a difference, something we see when complainants note care providers treated them with care and sensitivity even in difficult circumstances.

Over the coming year we will be launching initiatives to strengthen our own communication, transparency and reporting, such as launching a survey measuring complainants’ experiences with our office, to better understand how we can improve our service to Ontarians.

Download full report

Patient Ombudsman 2024/25

Patient Ombudsman’s message

What Patient Ombudsman does

2024/25 at a glance

New complaints to Patient Ombudsman by year

Spotlight issues

Spotlight 1 of 5: Resolutions by our office

Spotlight 2 of 5: Follow-up on women’s health/OB-GYN care

Spotlight 3 of 5: Follow-up on care in hospital emergency departments

Spotlight 4 of 5: Coordinated, planned discharge from hospitals

Spotlight 5 of 5: Using force and restraints to respond to challenging behaviours

Patient Ombudsman Investigations

Following through on recommendations

Investigations Recommendation Actions 2018-2025

Year/Investigation Type

2018

2021

2023

2024

2025

Complaints data

Who contacted Patient Ombudsman

Written complaints per 100,000 people in each Ontario Health region

Location of health care organizations

Location of complainants

Public hospitals: 57% of complaints

New complaints in 2024/25

Top complaints

Emerging and persistent themes

Long-term care homes: 7% of complaints

New complaints in 2024/25

Top complaints

Emerging and persistent themes

Home and Community Care Support services: 7% of complaints

New complaints in 2024/25

Top complaints

Emerging and persistent themes

Community surgical and diagnostic centres: 4% of complaints

New complaints in 2024/25

Top complaints

Emerging and persistent themes

Health services outside of Patient Ombudsman’s jurisdiction: 25% of complaints

New complaints in 2024/25

Top complaints

Emerging and persistent themes

Public hospitals: 53% of complaints

Top complaints

Long-term care homes: 8% of complaints

Top complaints

Home and Community Care Support services: 6% of complaints

Top complaints

Community surgical and diagnostic centres: 2% of complaints

Top complaints

Other: 31% of complaints

Public hospitals: 50% of complaints

Top complaints

Long-term care homes: 7% of complaints

Top complaints

Home and Community Care Support services: 6% of complaints

Top complaints

Other: 37% of complaints

Most frequent out-of-jurisdiction programs and services included in 2022/23 complaints

Hospitals: 61% of complaints

Top complaints

Long-term care homes: 10% of complaints

Top complaints

Home and Community Care: 7% of complaints

Top complaints

Other: 22% of complaints

Improving our efficiency and effectiveness

Summary