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
Ashford and St Peter's Hospitals NHS Foundation Trust (P-005026)
NHS in England
Partly Upheld
Referral
Treatment
AI summary: Mr W complained about delays in his father's AAA scan recall, inadequate assessment in the ED, and insufficient pain relief before his death.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-004986)
NHS in England
Closed After Initial Enquiries
Treatment
Diagnosis
AI summary: Ms A complained the Trust performed an unnecessary appendectomy without a second CT scan, failed to identify a kidney infection, and gave incorrect billing information.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-004574)
NHS in England
Partly Upheld
Diagnosis
AI summary: The Trust discharged her husband without further investigations, like a biopsy, for worsening symptoms, delaying cancer diagnosis and potentially a better outcome.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-004306)
NHS in England
Closed After Initial Enquiries
Diagnosis
Diagnosis
Communication
Treatment
Treatment
AI summary: Miss L complained about delayed viral meningitis diagnosis, untimely diagnostic tests, poor communication, inadequate pain relief, and inaccurate medical documentation, causing chronic fatigue.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-004138)
NHS in England
Closed After Initial Enquiries
Communication
Access
AI summary: Mrs A complained the Trust failed to respond to a GP, provided no consultant oversight, and did not monitor blood results for her mother, causing distress in her final weeks.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-004179)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: The Trust diagnosed her sister with stage four lung cancer too late, focusing on infection and delaying a PET scan, which Mrs O believes led to her terminal condition.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-003963)
NHS in England
Partly Upheld
End of life care
Nursing care
Treatment
AI summary: Mrs G complained the Trust failed to adequately monitor her mother's condition, perform risk assessments, give timely antibiotics, perform an angiography, assess fall risk, do a timely ABG test, or provide palliative care, leading to her traumatic death.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-003749)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Diagnosis
Communication
AI summary: Mrs O complained the Trust's inadequate blood monitoring and missed opportunities during scans led to her miscarriage and emotional distress.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-003702)
NHS in England
Partly Upheld
Transfer, discharge and aftercare
Diagnosis
End of life care
AI summary: Mrs B complained the Trust inappropriately discharged her husband multiple times, delayed diagnosis and treatment, and provided poor, delayed palliative care, causing suffering and a non-peaceful death.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-003642)
NHS in England
Closed After Initial Enquiries
Treatment
Treatment
AI summary: Mr F complained the Trust failed to follow his sickle cell protocol in ED, causing long waits for pain relief and admission. He also alleged poor inpatient care, refusal to discuss his condition, and ignored engagement.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-003570)
NHS in England
Closed After Initial Enquiries
Diagnosis
Diagnosis
Transfer, discharge and aftercare
Diagnosis
AI summary: Mrs H complained about delayed diagnosis of her husband's pulmonary arteriovenous malformation by two Trusts, causing deterioration and death. She also cited his discharge with low oxygen.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-003095)
NHS in England
Partly Upheld
Treatment
AI summary: Mr E complained doctors failed to provide appropriate support after discharge and inadequately treated his mother's significant health problems, including sepsis, dehydration, and delirium, leading to her distress and avoidable death.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-002995)
NHS in England
Closed After Initial Enquiries
Diagnosis
Transfer, discharge and aftercare
Diagnosis
AI summary: Mrs J complained about delayed diagnosis of her husband's breathlessness and his discharge with low oxygen, which she believes accelerated his death.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-002431)
NHS in England
Closed After Initial Enquiries
Treatment
Communication
AI summary: Mrs I complained Ashford and St Peter's Hospitals NHS Foundation Trust failed to discuss her husband's CT scans, explain his condition or why surgery wasn't possible.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-001885)
NHS in England
Partly Upheld
Nursing care
AI summary: Mrs A complained a midwife incorrectly referred her to social services and made inappropriate comments after childbirth, worsening her postnatal depression.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-001822)
NHS in England
Closed After Initial Enquiries
Referral
AI summary: Dr O complained the Trust failed to order agreed urgent gastrological investigations, causing her health to deteriorate and worsening symptoms.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-001616)
NHS in England
Closed After Initial Enquiries
Tests
Communication
Commissioning
Communication
AI summary: Mr A complained the Trust failed to advise them of BMI criteria and delayed scans for IVF treatment, causing them to miss eligibility. He also complained the consultant ignored a GP letter.
Ashford and St Peter's Hospitals NHS Foundation Trust (P-001464)
NHS in England
Closed After Initial Enquiries
Communication
AI summary: Miss U complained about poor communication and misinformation from the Trust while her father received palliative care, causing her additional stress and sadness.
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.