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
Northumbria Healthcare NHS Foundation Trust (P-005112)
NHS in England
Upheld
Treatment
Communication
Nursing care
Nursing care
Risk assessment
Complaint handling
Complaint handling
AI summary: Mr G complained about poor pressure care, lack of dementia support, inadequate fluids, catheter issues, inappropriate placement, and poor record keeping for his mother.
Northumbria Healthcare NHS Foundation Trust (P-004932)
NHS in England
Closed After Initial Enquiries
Drugs / medication
End of life care
Diagnosis
Diagnosis
Diagnosis
Diagnosis
Administration
Complaint handling
AI summary: Mr E complained about a failure to investigate his mother's symptoms, a delay in providing a CT scan, and an inappropriate appointment with a physician associate.
Northumbria Healthcare NHS Foundation Trust (P-004921)
NHS in England
Closed After Initial Enquiries
Referral
Referral
Nursing care
Referral
Referral
Referral
Nursing care
Continuing healthcare
Drugs / medication
Drugs / medication
Access
Complaint handling
AI summary: Ms B complained about failures in the care and treatment her partner received for leg wounds, including referral delays, inadequate dressings, and unjust removal from the practice.
Northumbria Healthcare NHS Foundation Trust (P-004354)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Mr A alleged inappropriate discharge led to his father's death from undiagnosed pneumonia, and the Trust failed to communicate adequately with the family.
Northumbria Healthcare NHS Foundation Trust (P-004302)
NHS in England
Closed After Initial Enquiries
Treatment
Communication
Record keeping and management
Treatment
AI summary: Mrs E complained about inconsistent explanations regarding a medical procedure, being made to wait in active labour, and staff failing to follow policy for her baby's blood test.
Northumbria Healthcare NHS Foundation Trust (P-003500)
NHS in England
Closed After Initial Enquiries
Treatment
Treatment
Complaint handling
AI summary: Mr R complained his vasectomy procedure was painful, required more anaesthetic, and led to complications and a further procedure. He also cited the Trust's lengthy and impersonal complaint process.
Northumbria Healthcare NHS Foundation Trust (P-003440)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
Referral
Communication
Treatment
End of life care
Communication
Treatment
End of life care
Referral
AI summary: Mrs E complained the Trust and Practice failed to arrange physiotherapy follow-ups, monitor health, recognise safeguarding concerns, or communicate with her about her father's care.
Northumbria Healthcare NHS Foundation Trust (P-003372)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs A complained the Trust inappropriately discharged Mr B and failed to treat infections, manage pain, or act on worsening health. She believes this led to his undignified death and seeks compensation and service improvements.
Northumbria Healthcare NHS Foundation Trust (P-003173)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs E complained her mother fell from a hospital bed, breaking a rib, and the Trust failed to inform her, leading to ongoing care needs and financial impact.
Northumbria Healthcare NHS Foundation Trust (P-003006)
NHS in England
Closed After Initial Enquiries
Choice and Consent
Surgery
AI summary: Mr A complained he was not informed about titanium screws or incorrect mesh placement during hernia operations. He also alleged he did not give informed consent for these procedures, causing pain and nerve damage.
Northumbria Healthcare NHS Foundation Trust (P-002895)
NHS in England
Upheld
Access
Access
None
AI summary: Mrs O complained staff incorrectly informed her about early scan criteria, failed to advise self-referral, and midwives missed opportunities to refer for an early scan.
Northumbria Healthcare NHS Foundation Trust (P-002651)
NHS in England
Not Upheld
Treatment
Access
Nursing care
Access
AI summary: Mr R complained the Trust failed to monitor or escalate his wife's Addison’s disease, leading to her death and denying her recovery opportunity.
Northumbria Healthcare NHS Foundation Trust (P-002142)
NHS in England
Partly Upheld
Treatment
Surgery
None
AI summary: Mr T complained about his late father's care, alleging improper care for a foot wound leading to infection, inappropriate administration of oxycodone, and an unconfirmed lung cancer diagnosis.
Northumbria Healthcare NHS Foundation Trust (P-002047)
NHS in England
Closed After Initial Enquiries
Record keeping and management
AI summary: The Trust did not accurately autopsy her father's body, causing anxiety about organ mix-up and exacerbating her grief.
Northumbria Healthcare NHS Foundation Trust (P-001282)
NHS in England
Partly Upheld
Transfer, discharge and aftercare
Drugs / medication
AI summary: Mr A complained the Practice prescribed his wife an antibiotic she had a previous adverse reaction to, causing severe illness and death, and the Trust transferred her too quickly.
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.