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-002333)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Choice and Consent
Diagnosis
Complaint handling
AI summary: Trust allegedly gave inappropriate end-of-life medication and incorrect dosages, wrongly diagnosed a condition, and failed to arrange a promised resolution meeting.
University Hospitals Birmingham NHS Foundation Trust (P-002256)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
Access
Communication
End of life care
AI summary: A son complained his dying father was publicly informed of his condition, discharged without support, lacked appropriate home assessment and transport, and received no bereavement counselling.
University Hospitals Birmingham NHS Foundation Trust (P-002265)
NHS in England
Closed After Initial Enquiries
Communication
Complaint handling
AI summary: Mrs A complained about her husband's care, including isolation issues, incorrect COVID-19 treatment, insensitive communication about his dying, and unauthorized cessation of medication.
University Hospitals Birmingham NHS Foundation Trust (P-003878)
NHS in England
Closed After Initial Enquiries
Nursing care
Treatment
Nursing care
Treatment
Complaint handling
Treatment
AI summary: Negligent care, including missed medication/fluid, poor personal care, and an inappropriate DNACPR, caused her father's health to decline and resulted in his death.
University Hospitals Birmingham NHS Foundation Trust (P-003284)
NHS in England
Upheld
Choice and Consent
Choice and Consent
Complaint handling
AI summary: The Trust allegedly failed to gain consent for and forced catheterisation on E, causing pain. There were also delays in handling Miss O's complaint.
University Hospitals Birmingham NHS Foundation Trust (P-002017)
NHS in England
Partly Upheld
Access
Treatment
AI summary: Mrs K complained about inadequate non-surgical treatment for wrist fractures, premature cast removal, ineffective physiotherapy, and incorrect recording of her fall details.
University Hospitals Birmingham NHS Foundation Trust (P-002002)
NHS in England
Closed After Initial Enquiries
None
None
None
AI summary: Mr Y complained his mother, Mrs Y, acquired a second infection as an inpatient and staff failed to inform him. He also criticised the Trust's complaint handling for not answering his questions.
University Hospitals Birmingham NHS Foundation Trust (P-001976)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Communication
Treatment
AI summary: Mrs N complained about the Trust's medication management for Ms A (too much glucose, missed meds, failed blood thinning), a DNACPR order without consent, poor sepsis management, and conflicting communication.
University Hospitals Birmingham NHS Foundation Trust (P-001903)
NHS in England
Closed After Initial Enquiries
Referral
Access
Abuse
Treatment
Treatment
AI summary: Miss O complained the Trust failed to admit her for stroke symptoms or refer her to brain injury services, and gave incorrect information. She also alleged WAH provided poor care, caused long A&E waits, and staff were verbally abusive.
University Hospitals Birmingham NHS Foundation Trust (P-001701)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr P complained the Trust prematurely discharged his wife, leading to a brain bleed, stroke, and life-changing injuries, asserting care fell below expected standards.
University Hospitals Birmingham NHS Foundation Trust (P-001700)
NHS in England
Closed After Initial Enquiries
None
AI summary: Clinicians at the Trust did not take Mrs I's endometriosis seriously, delayed treatment, and advised her to 'persevere', causing ongoing pain and affecting potential fertility.
University Hospitals Birmingham NHS Foundation Trust (P-001719)
NHS in England
Closed After Initial Enquiries
Treatment
Diagnosis
Treatment
AI summary: Mrs A complained staff refused to treat an abscess, misdiagnosed it multiple times, and failed to treat gangrene, ultimately leading to her leg amputation.
University Hospitals Birmingham NHS Foundation Trust (P-001545)
NHS in England
Closed After Initial Enquiries
Death, mortuary and post-mortem arrangements
Communication
Risk assessment
AI summary: Mr E complained his mother fell unsupervised, staff took her phone, and a nurse upset her, causing her death, seeking financial remedy.
University Hospitals Birmingham NHS Foundation Trust (P-001484)
NHS in England
Closed After Initial Enquiries
Complaint handling
AI summary: Mrs D complained the Trust's response was inaccurate, believing her husband's ICD malfunctioned and delivered excessive shocks, potentially causing his death.
University Hospitals Birmingham NHS Foundation Trust (P-001365)
NHS in England
Upheld
Treatment
Communication
Treatment
Transfer, discharge and aftercare
AI summary: Mrs O complained radiotherapy caused her husband's paralysis, alleging lack of prior risk advice, insufficient emotional support, failure to investigate symptoms, and inappropriate discharge.
University Hospitals Birmingham NHS Foundation Trust (P-001316)
NHS in England
Partly Upheld
Nursing care
Nursing care
AI summary: Daughter complained about inadequate monitoring and treatment of her mother's weight loss, nutrition, and mismanagement of a pressure ulcer by the Trust.
University Hospitals Birmingham NHS Foundation Trust (P-001229)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
Complaint handling
AI summary: Mr L complained doctors failed to act on his father Mr E's CT scan results and inappropriately discharged him, and that the Trust's complaint responses left questions unanswered.
University Hospitals Birmingham NHS Foundation Trust (P-001183)
NHS in England
Partly Upheld
Treatment
Transfer, discharge and aftercare
AI summary: Mrs E complained that after foot surgery, the wrong plaster was applied, preventing a surgical boot and forcing her to use a walking frame, causing damage to her right leg.
University Hospitals Birmingham NHS Foundation Trust (P-001219)
NHS in England
Closed After Initial Enquiries
Treatment
Treatment
AI summary: Ms P complained her late husband received inappropriate urology care, including inadequate investigations for raised PSA and insufficient follow-up after surgery, leading to bladder damage.
University Hospitals Birmingham NHS Foundation Trust (P-001129)
NHS in England
Closed After Initial Enquiries
Charges
AI summary: Mr E complained the Trust charged his mother over £6,000 for care after initially quoting £900, causing shock and financial difficulty.
University Hospitals Birmingham NHS Foundation Trust (P-001095)
NHS in England
Upheld
Transfer, discharge and aftercare
Transfer, discharge and aftercare
AI summary: Mr I complained the Trust discharged him without antibiotics and with a delayed post-operative review, leading to a severe finger infection requiring partial amputation.
University Hospitals Birmingham NHS Foundation Trust (P-001092)
NHS in England
Closed After Initial Enquiries
Nursing care
Communication
AI summary: Mrs A complained the Trust provided poor care to her late father, including insufficient fluids, communication failures, delayed cancer diagnosis, and lack of consent for a DNR.
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.