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
Royal Devon University Healthcare NHS Foundation Trust (P-005013)
NHS in England
Closed After Initial Enquiries
Tests
AI summary: Mrs A complained the Trust did not properly assess her father and allowed him to eat solid food, leading to his deterioration and death.
Royal Devon University Healthcare NHS Foundation Trust (P-004683)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
Administration
Communication
AI summary: Mrs S complained the Trust incorrectly discharged her from spinal care, provided insufficient discharge information, gave vague explanations, and failed to process a GP referral, causing distress and affecting her health.
Royal Devon University Healthcare NHS Foundation Trust (P-004450)
NHS in England
Partly Upheld
Surgery
Treatment
AI summary: Mr B complained the Trust inappropriately changed his planned anaesthetic for catheter insertion, causing trauma, bleeding, and triggering PTSD due to a missed bladder and hit vein.
Royal Devon University Healthcare NHS Foundation Trust (P-004412)
NHS in England
Closed After Initial Enquiries
Charges
AI summary: Mrs A complained the Trust incorrectly charged her mother for Acute Healthcare At Home care without consent, causing her significant stress during pregnancy.
Royal Devon University Healthcare NHS Foundation Trust (P-004353)
NHS in England
Closed After Initial Enquiries
Choice and Consent
Communication
Diagnosis
AI summary: The consultant refused a PICC line, leading to 66 cannulations, wrongly referred Ms H for psychiatric issues, and dismissed her gastroparesis diagnosis.
Royal Devon University Healthcare NHS Foundation Trust (P-004304)
NHS in England
Partly Upheld
Treatment
Communication
Referral
Diagnosis
Nursing care
Communication
AI summary: Mrs K complained about her husband's inadequate pain management, delayed communication of his cancer's spread, and slow involvement of the Speech and Language Therapy team.
Royal Devon University Healthcare NHS Foundation Trust (P-003648)
NHS in England
Closed After Initial Enquiries
Choice and Consent
Drugs / medication
Treatment
AI summary: Mr A complained the Trust failed to consider all his symptoms, monitor his blood appropriately, and follow an appropriate medication plan for his complex hypothyroidism, leading to distress.
Royal Devon University Healthcare NHS Foundation Trust (P-003320)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs A complained about her daughter's post-operative care, alleging the Trust dismissed infection symptoms, delayed antibiotics, triggering an MS flare, and causing severe, permanent physical decline and distress.
Royal Devon University Healthcare NHS Foundation Trust (P-003297)
NHS in England
Partly Upheld
Treatment
AI summary: Mrs E complained Royal Devon University Healthcare NHS Foundation Trust staff failed to communicate with her and her son, inappropriately discharged him without monitoring, and stopped his omeprazole prescription.
Royal Devon University Healthcare NHS Foundation Trust (P-003010)
NHS in England
Closed After Initial Enquiries
Treatment
Complaint handling
AI summary: Mr E complained the cardiology team inappropriately discharged him, that he was exposed to flu in poor conditions, and the Trust failed to respond to his complaint, leading to a second stroke and financial strain.
Royal Devon University Healthcare NHS Foundation Trust (P-002991)
NHS in England
Closed After Initial Enquiries
Treatment
Transfer, discharge and aftercare
AI summary: Mr O complained the Trust failed to treat his back pain in A&E and unfairly labelled him as aggressive, discharging him, which worsened his condition and delayed recovery.
Royal Devon University Healthcare NHS Foundation Trust (P-002971)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Choice and Consent
Communication
AI summary: Mrs I complained her mother received no pain relief as an inpatient, underwent treatments outside her care plan, and the family was misinformed about her condition, leading to an unprepared death.
Royal Devon University Healthcare NHS Foundation Trust (P-002856)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs O complained the Trust failed to conduct appropriate investigations and attempted an inappropriate discharge, causing profound worry and loss of faith.
Royal Devon University Healthcare NHS Foundation Trust (P-002760)
NHS in England
Closed After Initial Enquiries
Communication
Facilities and cleanliness
Communication
Communication
AI summary: Mr R complained about his father's care, including being left shoeless, unclean sheets, cold food, an open window, staff comments about his mother, and poor communication of his death.
Royal Devon University Healthcare NHS Foundation Trust (P-002632)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr H complained the Trust's paediatrician mismanaged his grandson's medication and lacked leadership, causing his mental health to deteriorate.
Royal Devon University Healthcare NHS Foundation Trust (P-002541)
NHS in England
Upheld
Diagnosis
Transfer, discharge and aftercare
AI summary: Ms V complained staff in A&E did not properly assess her or provide follow-up advice after an accident, leading to lasting cognitive, emotional, and behavioural issues. She sought apology and service improvements.
Royal Devon University Healthcare NHS Foundation Trust (P-002370)
NHS in England
Not Upheld
Access
AI summary: Mrs N complained the Trust delayed her double hip replacement due to a physiotherapist incorrectly referring her for spinal investigations, causing prolonged pain.
Royal Devon University Healthcare NHS Foundation Trust (P-001972)
NHS in England
Closed After Initial Enquiries
Drugs / medication
AI summary: Ms D complained about the 2014 prescription of Isotretinoin for acne rosacea, alleging it caused severe side effects affecting her arms and legs, preventing her from working.
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.