The HSE has only implemented 10 out of 36 Ombudsman recommendations three years after an investigation into the health service.
The Ombudsman Peter Tyndall says he is disappointed the HSE and hospitals have not done more to improve procedures, especially in relation to complaints.
At the time of the report in 2015, both the HSE and the Department of Health accepted all 36 recommendations which were aimed at:
In the report, Mr Tyndall acknowledges positive developments such as improved facilities for complaints officers and patients making complaints (Tallaght hospital), initiatives to ensure early resolution of complaints (St John’s Community hospital Sligo), and audits of patient complaints to assess the quality of the complaints process (RCSI hospital group).
However, the Ombudsman said: “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. ”