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
Manchester University NHS Foundation Trust (P-002811)
NHS in England
Closed After Initial Enquiries
Surgery
Complaint handling
AI summary: Miss S complained the Trust performed incorrect surgery on her left eye without consent and failed to provide a follow-up appointment after her complaint, causing pain and distress.
Manchester University NHS Foundation Trust (P-002740)
NHS in England
Partly Upheld
Transfer, discharge and aftercare
AI summary: Mr I alleged his father was prematurely discharged, not monitored for Sarilumab side effects, and communication was poor, contributing to his death.
Manchester University NHS Foundation Trust (P-002646)
NHS in England
Upheld
Communication
Communication
Death, mortuary and post-mortem arrangements
Nursing care
AI summary: Mrs G complained the Trust failed to notify her of her father's death, gave his property to someone else, and prevented her from seeing him on the ward.
Manchester University NHS Foundation Trust (P-002534)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Mrs U complained the Trust's ED staff failed to consider her cancer status, provide recommended antibiotics, or diagnose neutropenic sepsis timely, worsening her condition and hospital stay.
Manchester University NHS Foundation Trust (P-002479)
NHS in England
Closed After Initial Enquiries
None
AI summary: Miss R complained about her father's care before his death, alleging a delayed procedure and that the family was not promptly informed about a cardiac arrest during treatment.
Manchester University NHS Foundation Trust (P-002482)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
AI summary: Miss J complained the Trust discharged her mother prematurely and without adequate support, leading to readmission and subsequent death.
Manchester University NHS Foundation Trust (P-002410)
NHS in England
Closed After Initial Enquiries
Communication
AI summary: Mrs C complained Manchester University NHS Foundation Trust had poor communication regarding her husband's deteriorating health, COVID-19 diagnosis, and impending death.
Manchester University NHS Foundation Trust (P-002421)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Mrs U complained Manchester University NHS Foundation Trust failed to inform her of lung changes from CT scans, leading to a worse cancer outcome and re-triggered PTSD.
Manchester University NHS Foundation Trust (P-002350)
NHS in England
Closed After Initial Enquiries
Diagnosis
Treatment
AI summary: Ms A complained about negligent outpatient care, including misdiagnosis of fungal pneumonia, incorrect treatment, and inappropriate physiotherapy, which she claims put her life at risk.
Manchester University NHS Foundation Trust (P-002322)
NHS in England
Closed After Initial Enquiries
Administration
Complaint handling
AI summary: Ms R complained the Trust added an incorrect clinical code for a behavioural disorder to her records in 2013. She alleged this caused distress and a loss of faith in the Trust.
Manchester University NHS Foundation Trust (P-002480)
NHS in England
Upheld
Choice and Consent
Drugs / medication
AI summary: Mr C complained the Trust prescribed steroids for an eye condition without informing him of all possible side effects, leading to a mental health episode.
Manchester University NHS Foundation Trust (P-001988)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs U complained the Trust did not perform timely tests or prescribe recommended antibiotics in the emergency department, incorrectly stating she lacked neutropenic sepsis, which worsened her condition.
Manchester University NHS Foundation Trust (P-001896)
NHS in England
Upheld
Diagnosis
Communication
AI summary: Miss and Mrs B complained CAMHS delayed diagnosing Miss B with disruptive mood dysregulation disorder, and inadequately explained a referral, causing distress, educational setbacks, and family impact.
Manchester University NHS Foundation Trust (P-001894)
NHS in England
Closed After Initial Enquiries
Communication
End of life care
AI summary: Ms R complained the Trust failed to manage her mother's pain effectively before her death and exhibited poor communication, causing confusion and distress to the family.
Manchester University NHS Foundation Trust (P-001871)
NHS in England
Closed After Initial Enquiries
Treatment
Nursing care
Nursing care
AI summary: Ms G complained the Trust failed to ensure Mr K wore splints, delayed medication, ignored weight loss, provided poor mouth care, and delayed hospital treatment for pneumonia.
Manchester University NHS Foundation Trust (P-001868)
NHS in England
Closed After Initial Enquiries
Treatment
Diagnosis
Diagnosis
Treatment
Treatment
Treatment
AI summary: Mrs R complained her rehabilitation unit failed to provide proper support, staff were untrained, and did not call an ambulance after a fall, leading to misdiagnosis.
Manchester University NHS Foundation Trust (P-001663)
NHS in England
Closed After Initial Enquiries
None
None
None
Access
AI summary: The Trust's rheumatology department failed to offer support or monitoring for medication, a nurse did not help with side effects, a doctor was dismissive, and the Trust delayed its complaint response.
Manchester University NHS Foundation Trust (P-001677)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: The Trust did not allow enough time to consider treatment or read the consent form, and performed an intravitreal injection incorrectly, leading to vision loss and depression.
Manchester University NHS Foundation Trust (P-001535)
NHS in England
Not Upheld
Choice and Consent
AI summary: Ms D complained the Trust failed to investigate neck/shoulder pain, delayed MRI results, misinterpreted spinal scans, and refused a second opinion or referral for her hypermobility, causing prolonged pain.
Manchester University NHS Foundation Trust (P-001638)
NHS in England
Partly Upheld
Surgery
Diagnosis
AI summary: Mr R complained an angiogram on his father was unnecessary and rushed, and complications were mishandled, leading to his father's death.
Manchester University NHS Foundation Trust (P-001433)
NHS in England
Closed After Initial Enquiries
Access
AI summary: Ms N complained her late mother did not receive an urgent angiogram or an interpreter, and communication about her treatment was inadequate, contributing to her death after a cardiac arrest.
Manchester University NHS Foundation Trust (P-001272)
NHS in England
Partly Upheld
Treatment
Transfer, discharge and aftercare
AI summary: Mrs E complained the Trust failed to involve her in her mother's care, provide adequate personal/palliative care, timely diagnose a kidney infection, and maintain hygiene, leading to sepsis via a Hickman line.
Manchester University NHS Foundation Trust (P-001268)
NHS in England
Closed After Initial Enquiries
Treatment
Charges
Choice and Consent
AI summary: Miss G complained the Trust delayed a procedure, refused an itemised invoice, and pressured her into signing a consent form without recording her resuscitation wishes.
Manchester University NHS Foundation Trust (P-001072)
NHS in England
Upheld
Other - Health
None
Communication
AI summary: Ms A complained her deceased brother’s NG tube was wrongly inserted, causing fluid to enter his lung and contributing to his death. She also alleged poor communication about his cardiac arrest and inconsiderate handling of tissue donation.
Manchester University NHS Foundation Trust (P-001057)
NHS in England
Partly Upheld
Treatment
AI summary: Miss A complained she sustained skin damage, including burns and blisters, during shoulder surgery and was not informed about the injury by the Trust.
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.