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
Lewisham and Greenwich NHS Trust (P-005095)
NHS in England
Partly Upheld
Communication
Referral
Access
Access
Drugs / medication
Referral
AI summary: Mrs. A complained about a lack of communication regarding her sepsis diagnosis and a lack of follow-up appointments after discharge in January 2021.
Lewisham and Greenwich NHS Trust (P-005071)
NHS in England
Not Upheld
Drugs / medication
Communication
Drugs / medication
AI summary: Mrs L complained about inadequate aftercare advice and lack of antibiotics after gallbladder surgery, poor communication about risks, and a surgical procedure without pain relief.
Lewisham and Greenwich NHS Trust (P-005064)
NHS in England
Upheld
Drugs / medication
Diagnosis
Diagnosis
AI summary: Mr. P complained about the Trust's management of his late wife's medication, testing, and response to her pain, leading to her death.
Lewisham and Greenwich NHS Trust (P-004862)
NHS in England
Closed After Initial Enquiries
Treatment
Confidentiality, privacy and safeguarding
Communication
AI summary: Mr D complained about his brother Mr E's falls, inadequate Alzheimer's care, inappropriate restraint, and inaccurate records, also citing mistreatment of himself.
Lewisham and Greenwich NHS Trust (P-004853)
NHS in England
Closed After Initial Enquiries
Tests
End of life care
AI summary: Mrs P complained about the Trust's management of Mr B's care for a suspected clot and his end-of-life care, alleging delays and distress.
Lewisham and Greenwich NHS Trust (P-004582)
NHS in England
Closed After Initial Enquiries
Treatment
Communication
Complaint handling
AI summary: The Trust failed to provide adequate nutrition/hydration, respond to deterioration, consider depression history, or send pain medication information for Ms T.
Lewisham and Greenwich NHS Trust (P-004560)
NHS in England
Partly Upheld
Treatment
None
None
None
Treatment
AI summary: A daughter complained about her mother's care across three admissions, including pressure sores, sacral tear from bedpan use, diuretic withdrawal, oxygen mismanagement, hypoxia misdiagnosis, and inappropriate digoxin prescription.
Lewisham and Greenwich NHS Trust (P-004502)
NHS in England
Closed After Initial Enquiries
Diagnosis
Diagnosis
Transfer, discharge and aftercare
AI summary: Mr E and Miss G complained the Trust failed to investigate, misdiagnosed, and discharged their son S with red-flag symptoms, delaying cancer diagnosis and leading to his premature death.
Lewisham and Greenwich NHS Trust (P-004371)
NHS in England
Closed After Initial Enquiries
Tests
End of life care
End of life care
Tests
Communication
AI summary: Mrs E complained about delays in her father's care and discharge, an unfair COVID-19 test request, and false claims about medication delivery, causing distress.
Lewisham and Greenwich NHS Trust (P-004271)
NHS in England
Closed After Initial Enquiries
Diagnosis
Abuse
Choice and Consent
AI summary: Mr L complained Lewisham and Greenwich NHS Trust denied him essential treatment and left a cannula in his arm. He also alleged London Ambulance Service paramedics were disrespectful and refused his hospital choice.
Lewisham and Greenwich NHS Trust (P-003586)
NHS in England
Closed After Initial Enquiries
Treatment
Communication
Communication
AI summary: Miss Q complained Lewisham and Greenwich NHS Trust staff did not respond to her father's deterioration, failed to consult the family about his DNACPR order, and did not inform her of his death upon her arrival at the hospital.
Lewisham and Greenwich NHS Trust (P-003468)
NHS in England
Not Upheld
Treatment
Communication
Treatment
Nursing care
AI summary: Mrs A complained the Trust delayed an OGD scan for her sister, failed to treat a stomach bleed/ulcer, and kept her nil by mouth inappropriately, leading to her death.
Lewisham and Greenwich NHS Trust (P-003408)
NHS in England
Upheld
Communication
Communication
Access
Communication
Treatment
AI summary: Miss E complained about poor fibroid treatment, lack of information on fibroid size/risks, wrong advice on bleeding during pregnancy, and insensitive post-miscarriage consultation, alleging these led to her miscarriage.
Lewisham and Greenwich NHS Trust (P-003191)
NHS in England
Closed After Initial Enquiries
Diagnosis
Communication
AI summary: Ms R complained staff misdiagnosed an ankle fracture as peroneal tendonitis and later refused to provide DEXA scan results, causing her ongoing pain and distress.
Lewisham and Greenwich NHS Trust (P-003007)
NHS in England
Upheld
Diagnosis
Choice and Consent
AI summary: The Trust failed to communicate risks considering her memory, did not X-ray post-op, and delayed diagnosing a displaced femur, causing prolonged pain and long-term mobility issues.
Lewisham and Greenwich NHS Trust (P-002959)
NHS in England
Upheld
Diagnosis
Complaint handling
AI summary: Mrs N complained the Trust failed to diagnose her ovarian cancer in November 2022 and handled her subsequent complaint poorly, leading to private treatment and significant distress.
Lewisham and Greenwich NHS Trust (P-001929)
NHS in England
Partly Upheld
Nursing care
Treatment
AI summary: Ms T complained about a nurse's response to her mother's seizure, medication management, and delays in diagnosing meningoencephalitis, alongside poor complaint handling by the Trust.
Lewisham and Greenwich NHS Trust (P-001390)
NHS in England
Not Upheld
Drugs / medication
Treatment
Drugs / medication
Drugs / medication
Treatment
Nursing care
Complaint handling
AI summary: Mrs H complained the Trust failed to treat her father's UTI, administer medication, inappropriately sedated him, didn't perform brain scans or nursing observations, and didn't provide evidence of actions post-complaint.
Lewisham and Greenwich NHS Trust (P-001385)
NHS in England
Closed After Initial Enquiries
Complaint handling
Record keeping and management
Treatment
AI summary: Ms E complained the Trust gave her incorrect treatment, documented incorrect medication information, lost ECG reports, and failed to respond to her further concerns, causing her and her daughter PTSD.
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.