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
Mid and South Essex NHS Foundation Trust (P-005092)
NHS in England
Closed After Initial Enquiries
Treatment
Communication
AI summary: Mrs. A complained her father received tablet chemotherapy instead of intravenous, and the Trust failed to provide advice when his health deteriorated.
Mid and South Essex NHS Foundation Trust (P-005082)
NHS in England
Not Upheld
Nursing care
Complaint handling
Mr A complains about the care provided to his mother, Mrs C, by Mid and South Essex NHS Foundation Trust (the Trust) from 6 April to 5 May 2024.
Mid and South Essex NHS Foundation Trust (P-005073)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Miss O complained her father's death was caused by negligent care after a fall and surgery while he had pneumonia.
Mid and South Essex NHS Foundation Trust (P-004874)
NHS in England
Not Upheld
Transfer, discharge and aftercare
Nursing care
AI summary: Ms A complained her mother was discharged without all necessary medication and lacked nursing support at home, causing pain and distress near the end of her life.
Mid and South Essex NHS Foundation Trust (P-004300)
NHS in England
Closed After Initial Enquiries
Nursing care
Nursing care
Tests
Treatment
Treatment
AI summary: Miss J complained the Trust failed to monitor her mother's condition, manage pressure sores, and administer antibiotics correctly, causing premature death and suffering.
Mid and South Essex NHS Foundation Trust (P-004160)
NHS in England
Partly Upheld
Drugs / medication
Nursing care
Nursing care
Surgery
AI summary: Mrs G complained the Trust administered dapagliflozin without monitoring, failed to provide nutrition, and delayed Mr G's bypass surgery, leading to HHS, a heart attack, and his death.
Mid and South Essex NHS Foundation Trust (P-003991)
NHS in England
Partly Upheld
Treatment
Treatment
AI summary: Miss E complained about delayed investigation of her mother's ear symptoms and high blood pressure, and poor pain management during an ED visit. She believed these failings contributed to her mother's death.
Mid and South Essex NHS Foundation Trust (P-004037)
NHS in England
Upheld
Diagnosis
Treatment
Referral
End of life care
End of life care
Communication
AI summary: Mr R complained the Trust delayed investigating his mother's ovarian cancer, draining abdominal fluid, and commencing chemotherapy. He also alleged unsafe discharge, failure to ensure palliative care, and poor communication, causing her unnecessary suffering.
Mid and South Essex NHS Foundation Trust (P-003732)
NHS in England
Closed After Initial Enquiries
Nursing care
AI summary: Mr M complained his mother developed eight pressure sores during her hospital admission and was discharged with them, causing her agony and denying her a peaceful death.
Mid and South Essex NHS Foundation Trust (P-003672)
NHS in England
Closed After Initial Enquiries
Surgery
Surgery
Transfer, discharge and aftercare
Transfer, discharge and aftercare
AI summary: Mr V complained his surgery was performed incorrectly due to wrong information, he was prematurely discharged, and prescribed penicillin despite an allergy, leading to severe complications and lifelong impact.
Mid and South Essex NHS Foundation Trust (P-003537)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs T complained about the Trust's inadequate care for her mother's pressure ulcers, poor nursing, and inappropriate discharge without necessary support, leading to her death.
Mid and South Essex NHS Foundation Trust (P-003485)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Miss U complained the Trust misdiagnosed a joint injury, then refused to investigate worsening symptoms including pain, tingling, and numbness, causing prolonged pain and distress.
Mid and South Essex NHS Foundation Trust (P-003349)
NHS in England
Partly Upheld
Nursing care
AI summary: Staff allegedly failed to provide adequate nutrition/hydration, ensure physiotherapy, and discharged Mr I when he was unfit, leading to his death after nine days.
Mid and South Essex NHS Foundation Trust (P-003272)
NHS in England
Not Upheld
Diagnosis
Treatment
AI summary: Mrs R complained Mid and South Essex NHS Foundation Trust failed to carry out appropriate investigations to diagnose and treat her father's condition, which she believes led to his death.
Mid and South Essex NHS Foundation Trust (P-003255)
NHS in England
Closed After Initial Enquiries
Referral
Complaint handling
Treatment
Administration
Complaint handling
AI summary: Mr O complained the Trust failed to prevent his fall, delayed rehabilitation, treated him for incorrect blood pressure, didn't inform other departments, and provided inaccurate records.
Mid and South Essex NHS Foundation Trust (P-003038)
NHS in England
Closed After Initial Enquiries
Diagnosis
Communication
AI summary: Trust did not appropriately assess Miss T's symptoms or call her MS nurse during ED visits, delaying infection diagnosis and treatment, which she claims almost caused her death.
Mid and South Essex NHS Foundation Trust (P-003091)
NHS in England
Closed After Initial Enquiries
Treatment
Administration
AI summary: Mr L and Mrs M complained the Trust inappropriately discharged their daughter with sepsis, leading to her death. They also raised concerns about a security guard's behaviour and receiving an empty memory box.
Mid and South Essex NHS Foundation Trust (P-003088)
NHS in England
Partly Upheld
Transfer, discharge and aftercare
Choice and Consent
AI summary: Mrs D complained her mother was inappropriately discharged without proper capacity assessment or consideration of safety concerns, leading to readmission and her mother's death in hospital.
Mid and South Essex NHS Foundation Trust (P-002996)
NHS in England
Closed After Initial Enquiries
Tests
Record keeping and management
Transfer, discharge and aftercare
AI summary: Mr K complained the Trust delayed his mother's COVID-19 test, made incorrect records, and discharged her without pain relief or suitable clothing, risking his family's health and increasing his mother's pain.
Mid and South Essex NHS Foundation Trust (P-002818)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Staff allegedly failed to inform Miss A's family, promptly investigate/treat her grandfather's worsening condition, and appropriately manage his pressure ulcer, fluid, and nutrition.
Mid and South Essex NHS Foundation Trust (P-002730)
NHS in England
Not Upheld
Diagnosis
Treatment
Communication
Nursing care
AI summary: Mrs A complained the Trust delayed Mr A's biopsy and mesothelioma diagnosis, failed to address his shoulder pain, and did not meet his nutritional needs.
Mid and South Essex NHS Foundation Trust (P-002439)
NHS in England
Closed After Initial Enquiries
Death, mortuary and post-mortem arrangements
Treatment
Treatment
Drugs / medication
Nursing care
AI summary: Miss I complained the Trust failed to treat her mother's post-surgery infection, gave incorrect advice, and provided poor nursing care, which she believes caused her mother's death.
Mid and South Essex NHS Foundation Trust (P-002263)
NHS in England
Closed After Initial Enquiries
Choice and Consent
Treatment
Transfer, discharge and aftercare
AI summary: A patient complained about COVID-19 care, including signing an unreadable consent form, an oxygen machine running out of water, lack of an OT appointment, and adverse effects from steroid treatment.
Mid and South Essex NHS Foundation Trust (P-002249)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Miss E complained the Trust misdiagnosed her mother's brain infection as a tumour and failed to identify a pelvic abscess, leading to sepsis and her mother's death.
Mid and South Essex NHS Foundation Trust (P-001570)
NHS in England
Closed After Initial Enquiries
Treatment
Communication
AI summary: Ms C complained the Trust failed to closely monitor Mr C, who was agitated, leading to his death. She also cited conflicting statements from staff about his end-of-life care.
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.