Ombudsman Peter Tyndall has expressed his disappointment that the Health Service Executive has not fully implemented the recommendations made in his 2015 investigation into the healthcare system.

The Ombudsman's 2015 report, Learning to Get Better, found that many people were afraid to complain about the treatment they receive in hospitals and that many hospitals were not learning important lessons from complaints they receive.

The HSE and Department of Health accepted all 36 recommendations in the report, which were aimed at:

making it easy for people to complain

ensuring that people have access to an effective independent advocacy service

establishing a single, consistent complaints system and

ensuring that the most serious complaints are examined independently.

Today, the Ombudsman published Learning to Get Better: Progress Report which found that only 10 of the recommendations were fully implemented by the HSE, while 17 were partially implemented and nine were either not implemented or are still being considered.

In the report, the Ombudsman acknowledges positive developments, such as improved handling of complaints at some hospitals.

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."

The Ombudsman said that often people have to make multiple complaints to have their issue addressed, the HSE's Complaint Management System is not used in all areas of the HSE, and not every voluntary hospital can accept complaints online.

He called on the HSE and Department of Health to build on the progress that has been made and ensure that all the recommendations in his report are fully implemented across the entire healthcare system.