PHSO Casework Decisions
3,622 published casework decisions from the Parliamentary and Health Service Ombudsman (Apr 2021–Mar 2026). PHSO selects a subset of completed investigations for public publication — these 3,622 decisions represent approximately 1.1% of the 321,459 total complaints received across the same period. Source: decisions.ombudsman.org.uk.
3,622
Published Decisions
3,089
Health
533
Parliamentary (Govt)
18%
Upheld / Partly Upheld
University Hospitals Birmingham NHS Foundation Trust (P-004204)
NHS in England
Upheld
Drugs / medication
Treatment
Drugs / medication
Treatment
Communication
Complaint handling
AI summary: Mr H complained about incorrect medication instructions, delayed scans/treatment, incorrect prescriptions, lack of mobility assistance, poor communication, and a long complaint response, worsening his condition.
University Hospitals Birmingham NHS Foundation Trust (P-004176)
NHS in England
Upheld
None
AI summary: The Trust failed to properly investigate her mother's bowel symptoms, missing a blockage, which, combined with continued feeding and enemas, caused perforation and her premature death.
University Hospitals Birmingham NHS Foundation Trust (P-004006)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs H complained the Trust delayed her bone cancer treatment, leading to the cancer spreading, her neck collapsing, and hospitalisation, causing significant pain and anxiety.
University Hospitals Birmingham NHS Foundation Trust (P-003814)
NHS in England
Partly Upheld
Tests
Transfer, discharge and aftercare
Tests
AI summary: Mrs N complained the Trust failed to investigate her husband's high white cell counts and bowel issues, discharged him during an MS relapse, and did not complete skin assessments or provide a colonoscopy.
University Hospitals Birmingham NHS Foundation Trust (P-003780)
NHS in England
Not Upheld
Transfer, discharge and aftercare
AI summary: Miss R complained the Trust unsafely discharged her unwell mother, Ms R, leading to her collapse, readmission, and subsequent death from sepsis shortly after.
University Hospitals Birmingham NHS Foundation Trust (P-003766)
NHS in England
Closed After Initial Enquiries
Communication
Surgery
Surgery
Administration
AI summary: Ms R alleged the Trust failed to accurately assess surgical risks, consider health conditions, access records, or provide correct post-surgery care for Mrs R, leading to her death.
University Hospitals Birmingham NHS Foundation Trust (P-003623)
NHS in England
Upheld
Communication
Diagnosis
Communication
Surgery
AI summary: Mrs I complained University Hospitals Birmingham NHS Foundation Trust failed to investigate a pancreatic mass, delayed reversal surgery, missed pancreatic cancer on a scan, delayed diagnosis, and failed to communicate with her family about her father's condition and palliative care.
University Hospitals Birmingham NHS Foundation Trust (P-003459)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr X complained the Trust prematurely placed a DNR notice, failed to manage pneumonia recovery, inadequately managed nutrition, and didn't act on sepsis signs, leading to his mother's death.
University Hospitals Birmingham NHS Foundation Trust (P-003798)
NHS in England
Partly Upheld
Communication
Complaint handling
Nursing care
AI summary: Mrs R complained staff did not listen to her father's unwellness and the Trust failed to provide regular BSL interpreters, instead using her children. She also questioned the complaint meeting interpreter and response.
University Hospitals Birmingham NHS Foundation Trust (P-003385)
NHS in England
Closed After Initial Enquiries
Surgery
Communication
Communication
AI summary: Mrs A complained the Trust incorrectly stated a consultant performed her husband's surgery and failed to communicate his condition, leading to severe health impacts and distress.
University Hospitals Birmingham NHS Foundation Trust (P-003341)
NHS in England
Closed After Initial Enquiries
None
AI summary: Mrs A complained the Trust caused an undetected tear during ureteroscopy in May 2021, leading to severe pain, a nephrostomy, and significant kidney damage.
University Hospitals Birmingham NHS Foundation Trust (P-003359)
NHS in England
Closed After Initial Enquiries
Treatment
Nursing care
Diagnosis
Abuse
AI summary: Dr Y complained about numerous care failings for Mr Z, including medication overdose, inappropriate ward moves, neglected personal care, delayed tests, and racial abuse, leading to his death.
University Hospitals Birmingham NHS Foundation Trust (P-003208)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr L complained the Trust failed to provide his mother with take-home potassium supplements and safety netting at discharge, leading to her cardiac arrest and brain damage.
University Hospitals Birmingham NHS Foundation Trust (P-003107)
NHS in England
Partly Upheld
None
None
Communication
Complaint handling
AI summary: Mr H complained his partner, Mrs I, was left alone with sepsis, fell, and broke her ankle. He also alleged the Trust failed to notify him of her admission or communicate, and delayed complaint responses.
University Hospitals Birmingham NHS Foundation Trust (P-003014)
NHS in England
Closed After Initial Enquiries
None
AI summary: Trust failed to identify Mrs L's right leg was shorter after hip surgery, leading to mobility issues, falls, and impacting her independence.
University Hospitals Birmingham NHS Foundation Trust (P-002926)
NHS in England
Closed After Initial Enquiries
Nursing care
AI summary: Miss I complained her father's condition deteriorated from able-bodied to disabled, leading to his death, and that the family was pressured into a DNR order and denied visits.
University Hospitals Birmingham NHS Foundation Trust (P-002912)
NHS in England
Closed After Initial Enquiries
Detention
Administration
AI summary: Mr A complained the Trust unlawfully detained him without reason or proper guidelines, and failed to provide him with DoLS documents during detention or discharge.
University Hospitals Birmingham NHS Foundation Trust (P-002877)
NHS in England
Partly Upheld
Communication
Diagnosis
Transfer, discharge and aftercare
Nursing care
Communication
AI summary: Mrs T complained about poor communication, a missed dementia diagnosis, inadequate aftercare, premature discharge, and missed observations for her father, believing these led to his death.
University Hospitals Birmingham NHS Foundation Trust (P-002816)
NHS in England
Partly Upheld
Referral
Communication
Treatment
Complaint handling
Communication
Death, mortuary and post-mortem arrangements
AI summary: Mrs A complained about delayed respiratory referral, poor communication about heart failure seriousness, conflicting alcohol advice, delayed oxygen treatment for Mr A, and inadequate complaint handling.
University Hospitals Birmingham NHS Foundation Trust (P-002824)
NHS in England
Closed After Initial Enquiries
Communication
Nursing care
COVID-19
Record keeping and management
Transfer, discharge and aftercare
AI summary: The Trust allegedly kept Mrs G's mother in hospital unnecessarily, mismanaged her nutrition/hydration, failed to communicate deterioration, and made incorrect discharge record entries.
University Hospitals Birmingham NHS Foundation Trust (P-002735)
NHS in England
Partly Upheld
Treatment
Tests
Tests
Treatment
Complaint handling
Choice and Consent
AI summary: Mr A complained the Trust failed to escalate his wife’s care, didn't perform observations frequently enough, delayed test results, and incorrectly labelled blood samples and inserted a PICC line.
University Hospitals Birmingham NHS Foundation Trust (P-002590)
NHS in England
Closed After Initial Enquiries
Diagnosis
Treatment
AI summary: Mrs E complained the Trust delayed her husband's cancer diagnosis for three years and a doctor allegedly deprived him of oxygen during a cardiac arrest, leading to his death.
University Hospitals Birmingham NHS Foundation Trust (P-002466)
NHS in England
Upheld
Communication
None
Nursing care
Transfer, discharge and aftercare
Death, mortuary and post-mortem arrangements
AI summary: Mrs R complained her grandmother received poor hygiene care, was discharged without a care package or oxygen instructions, and capacity for a DNAR form was questionable.
University Hospitals Birmingham NHS Foundation Trust (P-002483)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs O complained nurses mishandled her husband's oxygen, causing cardiac arrest, and an inappropriate, failed pleural aspiration led to a lung puncture and his death.
University Hospitals Birmingham NHS Foundation Trust (P-002293)
NHS in England
Not Upheld
Diagnosis
AI summary: Trust did not perform appropriate tests for a suspected blood clot in Miss C's leg, allegedly leading to an amputation and significant emotional distress.
Upheld / Partly Upheld
259 + 397
18% of decisions found fault with the organisation complained about.
Not Upheld
247
Complaint investigated but no fault found. 1 resolved during investigation.
Closed After Initial Enquiries
2,718
PHSO decided not to proceed to full investigation.
Most complained-about:
HM Revenue and Customs (80), University Hospitals Birmingham NHS Foundation Trust (72), NHS England (62), Manchester University NHS Foundation Trust (50), HM Courts and Tribunals Service (48).
Published Decisions Over Time
Excludes 2,718 closed before investigation. Quarterly, by outcome.
Annual Complaints (PHSO-wide)
Official PHSO annual statistics across all organisations
| Year | Received | Investigated | Upheld | Upheld % | Remedy % |
|---|---|---|---|---|---|
| 2019-20 | 54,478 | 12,275 | 1,216 | 9.9% | 0% |
| 2020-21 | 44,139 | 7,822 | 617 | 7.9% | 0% |
| 2021-22 | 62,553 | 13,426 | 727 | 5.4% | 0% |
| 2022-23 | 61,297 | 15,734 | 782 | 5.0% | 0% |
| 2023-24 | 63,471 | 17,321 | 946 | 5.5% | 0% |
| 2024-25 | 35,521 | 10,070 | 519 | 5.2% | 0% |
Remedy % = percentage of PHSO remedies complied with on time
Top Themes
Themes by Upheld Rate
AI-classified themes across PHSO casework decisions
| Theme | Decisions | Upheld | Rate |
|---|---|---|---|
| Delayed Recognition of Deterioration | 747 | 184 | 25% |
| Complaint record keeping failures | 632 | 108 | 17% |
| Clinical negligence harms learning | 460 | 92 | 20% |
| Care plan failures | 436 | 121 | 28% |
| Care and discharge planning | 288 | 77 | 27% |
| No person-centred care | 215 | 46 | 21% |
| Inaccurate and inaccessible patient records | 204 | 37 | 18% |
| Patient dignity and privacy | 147 | 40 | 27% |
| Inadequate Pre-Operative Risk Assessment | 136 | 44 | 32% |
| Duty of Candour implementation | 134 | 43 | 32% |
| Medication Contamination/Misadministration | 128 | 33 | 26% |
| DWP policy impact assessment | 106 | 12 | 11% |
| Poor health and social care integration | 97 | 21 | 22% |
| Mental Health Crisis Referral Delays | 74 | 10 | 14% |
| Coroner family information gaps | 74 | 25 | 34% |
PHSO Complaint Categories
PHSO Categories by Upheld Rate
PHSO's own issue classifications — broad categories such as 'Treatment' cover a wide range of clinical complaints
| Category | Decisions | Upheld | Rate |
|---|---|---|---|
| Treatment | 1,610 | 418 | 26% |
| Diagnosis | 850 | 206 | 24% |
| Communication | 792 | 233 | 29% |
| Complaint handling | 534 | 161 | 30% |
| Drugs / medication | 463 | 130 | 28% |
| Nursing care | 388 | 154 | 40% |
| Access | 363 | 87 | 24% |
| Transfer, discharge and aftercare | 353 | 119 | 34% |
| Referral | 262 | 58 | 22% |
| Administration | 191 | 30 | 16% |
| End of life care | 170 | 50 | 29% |
| Choice and Consent | 165 | 48 | 29% |
| Continuing healthcare | 160 | 14 | 9% |
| Surgery | 145 | 32 | 22% |
| Record keeping and management | 133 | 30 | 23% |
Organisation Accountability
Combines PHSO annual complaint statistics (volume, remedy compliance) with published decisions portal data (uphold rate). Sorted by upheld rate for organisations with 5+ investigated decisions. Benchmark: 73% average upheld rate among fully investigated decisions. This differs from the headline 18% figure, which includes all 3,340 published decisions — most of which were closed before full investigation (upheld/not upheld only applies to fully investigated cases). Sparklines show complaint volumes received 2019–20 → 2024–25.
Received = complaints received in most recent year (PHSO annual data). Remedy compliance = % of PHSO-recommended remedies complied with across all available years. — = no data in that dataset for this organisation.