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
The Princess Alexandra Hospital NHS Trust (P-005089)
NHS in England
Partly Upheld
Nursing care
AI summary: Mr. A complained that his mother was left unaccompanied in a radiology recovery room, where she suffered a cardiac arrest, which he believes was avoidable.
Countess of Chester Hospital NHS Foundation Trust (P-005094)
NHS in England
Partly Upheld
Diagnosis
Treatment
Treatment
Nursing care
Nursing care
AI summary: Mr. L complained about the Trust's misdiagnosis, inadequate hydration and feeding, incorrect medication, and poor stoma care for his wife during her hospital admission.
University Hospitals Dorset NHS Foundation Trust (P-005093)
NHS in England
Partly Upheld
Transfer, discharge and aftercare
Choice and Consent
AI summary: Mrs. O complained that the Trust did not discuss surgical options, provide post-operative information, or offer support after her haemorrhoidal artery ligation operation.
A practice in the Tonbridge and Malling area (P-005088)
NHS in England
Closed After Initial Enquiries
Administration
AI summary: Mr. K complained the Practice provided an inappropriate fit note and refused to amend it, failed to cater to his reasonable adjustment request, and took too long to respond.
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.
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.
A practice in the City of Peterborough area (P-005077)
NHS in England
Closed After Initial Enquiries
Referral
AI summary: Mrs A complained the Practice failed to arrange mental health support, follow up on blood test results, act on referral requests, or refer Miss X for an urgent mental health assessment.
York and Scarborough Teaching Hospitals NHS Foundation Trust (P-005078)
NHS in England
Closed After Initial Enquiries
Diagnosis
Transfer, discharge and aftercare
Mr O complains about the care and treatment provided to his wife by a hospital Trust. Mr O says the Trust failed to act on the results of scans and did not admit his wife to a ward in an acceptable timeframe.
University Hospitals Sussex NHS Foundation Trust (P-005076)
NHS in England
Closed After Initial Enquiries
Continuing healthcare
Referral
AI summary: Miss E complained that the Trust discharged her from the ED when she felt unsafe and performed an inappropriate internal pelvic scan.
Cambridge University Hospitals NHS Foundation Trust (P-005081)
NHS in England
Partly Upheld
Nursing care
Diagnosis
Access
Treatment
Treatment
Nursing care
Risk assessment
Communication
Treatment
End of life care
Ms F complains about various aspects of care and treatment provided to her late father Mr F between April and August 2022 including medication management, nursing care including nutrition and fluids management, physiotherapy input, miscommunication, and falls management.
Cambridge University Hospitals NHS Foundation Trust (P-005075)
NHS in England
Upheld
Communication
Treatment
Diagnosis
Treatment
AI summary: Miss Y complained the Trust failed to recognise her grandmother's deterioration, inform her of this, and relax visiting restrictions before her death.
County Durham and Darlington NHS Foundation Trust (P-005074)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
Treatment
Treatment
AI summary: Miss A complained about delays in treatment for her lower back pain from multiple Trusts since 2012, including a failure to arrange scans or consider surgery.
East of England Ambulance Service NHS Trust (P-005085)
NHS in England
Closed After Initial Enquiries
Access
Mrs O complains about aspects of care provided to her son, E, by East of England Ambulance Service NHS Trust (the Trust) during an emergency services call on 24 December 2024. Specifically, she complains E was actively having a seizure, and the Trust did not initially correctly categorise the call as a category one call.
Norfolk and Suffolk NHS Foundation Trust (P-005084)
NHS in England
Closed After Initial Enquiries
Communication
Access
Complaint handling
Mr U complains about aspects of care provided by Norfolk and Suffolk NHS Foundation Trust (the Trust). Specifically, he complains the Trust delayed providing him a copy of his care plan, gave inadequate bereavement support and handled his complaint issues poorly.
HM Courts and Tribunals Service (P-005072)
UK Government
Closed After Initial Enquiries
Courts
Courts
AI summary: Mr B complained about delays in receiving court orders and lack of communication from HMCTS, leading to extra expenses.
A practice in the South Oxfordshire area (P-005083)
NHS in England
Closed After Initial Enquiries
Access
Access
Access
Referral
Complaint handling
Mr A complains about the care a Practice in the Oxfordshire area gave him between September and November 2024. He complains the Practice delayed processing and gave wrong information about autism right to choose referrals, blood tests and how regularly blood tests/ultrasound scans should be undertaken. It incorrectly processed and gave incorrect information in relation to the long-COVID service, made errors when referring him to the sarcoma service and did not give progress updates or respond to his requests for answers.
Insolvency Service (P-005080)
UK Government
Closed After Initial Enquiries
Employment and low income benefits
AI summary: Mr. H complained that the Insolvency Service failed to provide him with redundancy payments from the National Insurance Fund.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust (P-005087)
NHS in England
Partly Upheld
Communication
Diagnosis
Treatment
Access
AI summary: Mrs. R complained about a lack of communication, failure to explore treatment options, a delayed echocardiogram, and no face-to-face asthma consultation for her grandmother.
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.
UK Visas and Immigration (UKVI) (P-005079)
UK Government
Closed After Initial Enquiries
Nationality, visas and residency
AI summary: Mr A complained UKVI delayed returning his passport, causing delays to a fresh application, preventing him from entering the UK and starting work.
A practice in the Preston area (P-005086)
NHS in England
Closed After Initial Enquiries
Treatment
Treatment
AI summary: Mrs I complained the practice inappropriately decided on a 'do not resuscitate' order for her father without family consultation.
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.
Tees, Esk and Wear Valleys NHS Foundation Trust (P-005070)
NHS in England
Closed After Initial Enquiries
Treatment
Risk assessment
AI summary: Mr Y complained the community mental health team failed to provide consistent, appropriate, and timely support, including a safety plan and consistent care coordinator, worsening his mental health.
University Hospital Southampton NHS Foundation Trust (P-005067)
NHS in England
Closed After Initial Enquiries
Communication
Access
AI summary: Miss A complained about a three-year delay for spinal cord stimulation surgery, poor communication, and failure to consider her desire to start a family.
Gloucestershire Hospitals NHS Foundation Trust (P-005069)
NHS in England
Closed After Initial Enquiries
Tests
Complaint handling
AI summary: Mr H complained about delays in reviewing his test results and inaccurate/delayed responses to his complaint, causing him to suffer heart palpitations and breathing problems.
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.