The Ombudsman, Peter Tyndall, has said that he is disappointed that the HSE has failed to fully implement recommendations he made as part of an investigation into the healthcare system back in 2015.

His 2015 report, Learning to Get Better, revealed that many people were afraid to complain about the hospital treatment they had received. Furthermore, many hospitals were not learning any lessons from the complaints that they received.

The report made 36 recommendations aimed at making it easier for people to complain and ensuring that the most serious complaints are examined independently. The HSE and Department of Health accepted all 36.

However, in a new progress report which has just been published, the Ombudsman found that just 10 of the 36 recommendations have been fully implemented by the HSE. Seventeen have been partially implemented, seven have not been implemented, while two are under consideration.

"We have carried out an extensive investigation into hospital complaints systems and we found that they fall short of what we would expect from effective systems. People can die when lessons are not learned from complaints," Mr Tyndall explained.

He noted that people often have to make a number of complaints before their issue is addressed, and the HSE's Complaint Management System is not used in all areas of the HSE.

Furthermore, some voluntary hospitals cannot even accept complaints online.

Mr Tyndall called on the HSE and the Department of Health to ensure that all of the original recommendations are fully implemented across the entire health system.

The progress report can be viewed here