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
Showing 19 results matching "Chelsea and Westminster Hospital NHS Foundation Trust"
Chelsea and Westminster Hospital NHS Foundation Trust (P-004978)
NHS in England
Closed After Initial Enquiries
Treatment
Treatment
Complaint handling
Access
AI summary: Dr T complained about delayed/inappropriate treatment for a burn, leading to scarring, side effects, and private treatment. She also complained PALS did not respond appropriately, affecting her subsequent care and leading to appointment cancellations.
Chelsea and Westminster Hospital NHS Foundation Trust (P-004912)
NHS in England
Not Upheld
End of life care
Treatment
Treatment
Treatment
Nursing care
AI summary: Miss C complained about failures in her father's end-of-life care, including incorrect placement, inappropriate treatments, and repeated requests to mobilise when he was too weak.
Chelsea and Westminster Hospital NHS Foundation Trust (P-004572)
NHS in England
Closed After Initial Enquiries
Communication
Tests
AI summary: The Trust failed to communicate her birth plan for a C-section and poorly communicated about her son's heart murmur, causing distress and impacting mental health.
Chelsea and Westminster Hospital NHS Foundation Trust (P-004403)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: The Trust declined fertility treatment due to her high BMI and later refused to reconsider new medical information explaining her BMI.
Chelsea and Westminster Hospital NHS Foundation Trust (P-004217)
NHS in England
Upheld
Diagnosis
Treatment
Diagnosis
Treatment
AI summary: Mr A complained the Trust failed to diagnose his cousin's oesophageal cancer, manage malnutrition, follow up on procedures, and take his health concerns seriously, contributing to his death.
Chelsea and Westminster Hospital NHS Foundation Trust (P-003759)
NHS in England
Closed After Initial Enquiries
Treatment
Drugs / medication
Treatment
Drugs / medication
AI summary: Mr X complained his mother had a knee operation despite a swollen foot, inappropriate anaesthetic, pneumonia, and missed medication, negatively impacting her outcome.
Chelsea and Westminster Hospital NHS Foundation Trust (P-003264)
NHS in England
Partly Upheld
Treatment
Access
Communication
Diagnosis
Diagnosis
Referral
AI summary: Mr A complained the GP Practice failed to appropriately assess his wife's urgent symptoms and refer her, causing delayed diagnosis. He also alleged Imperial College Healthcare NHS Trust misdiagnosed and missed breathing issues, and Chelsea and Westminster Hospital NHS Foundation Trust had care failings.
Chelsea and Westminster Hospital NHS Foundation Trust (P-003157)
NHS in England
Not Upheld
Diagnosis
AI summary: Ms J complained doctors misdiagnosed her husband with post-COVID complications, delaying his organising pneumonia diagnosis and treatment, which she believes caused his death.
Chelsea and Westminster Hospital NHS Foundation Trust (P-003062)
NHS in England
Upheld
None
None
None
AI summary: Mrs U complained about her uncle's inappropriate discharge, incorrect falls risk assessment, lack of a Zimmer frame, and inaccurate information about his mobility, leading to readmission.
Chelsea and Westminster Hospital NHS Foundation Trust (P-002983)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs H complained the Trust failed to timely diagnose her husband's cancer, poorly communicated his condition, did not prevent his escape, and inadequately informed her about tumour lysis syndrome.
Chelsea and Westminster Hospital NHS Foundation Trust (P-002549)
NHS in England
Partly Upheld
Nursing care
AI summary: Mrs Q complained staff failed to drain her husband's NG tube collection bag and ensure its correct placement, leading to acid aspiration, pneumonia, and a traumatic death.
Chelsea and Westminster Hospital NHS Foundation Trust (P-002523)
NHS in England
Closed After Initial Enquiries
Complaint handling
Surgery
AI summary: Mrs U complained her hair was shaved during cyst removal against her wishes and only some cysts were removed, causing distress, and that the Trust's complaint investigation was biased.
Chelsea and Westminster Hospital NHS Foundation Trust (P-002419)
NHS in England
Closed After Initial Enquiries
None
AI summary: Miss O complained about continuous neglectful care, including delayed diagnosis, poor follow-up, inaccurate medical notes, and improper complaint handling by the Trust.
Chelsea and Westminster Hospital NHS Foundation Trust (P-002385)
NHS in England
Closed After Initial Enquiries
None
AI summary: Mr E complained the Trust failed to provide treatment for his wife's sarcopenia, lacked a care plan, and made no referrals or scans after a fall.
Chelsea and Westminster Hospital NHS Foundation Trust (P-003890)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs L complained her husband contracted COVID-19, received inadequate liver disorder treatment, suffered falls due to poor risk management, and experienced poor communication. She believes this contributed to his death.
Chelsea and Westminster Hospital NHS Foundation Trust (P-001893)
NHS in England
Closed After Initial Enquiries
Surgery
AI summary: Mr A complained about an unconsented knee procedure, surgical burns, and inadequate discharge. He also alleged the Trust failed to investigate the burns and close his complaint properly.
Chelsea and Westminster Hospital NHS Foundation Trust (P-001849)
NHS in England
Closed After Initial Enquiries
Access
AI summary: Ms E complained the Trust unfairly denied her Roux-En-Y surgery due to mental health instability and failed to adequately support her mental health needs.
Chelsea and Westminster Hospital NHS Foundation Trust (P-001304)
NHS in England
Closed After Initial Enquiries
Access
Communication
Communication
AI summary: Ms U complained about her post-hip replacement care, alleging delayed communication about leg length difference, unaddressed concerns, and staff anger, leading to distress and PTSD.
Chelsea and Westminster Hospital NHS Foundation Trust (P-001139)
NHS in England
Closed After Initial Enquiries
Communication
Communication
Complaint handling
AI summary: Miss A complained the Trust failed to arrange apologies, disregarded her concerns about moving her vulnerable, shielding son, and did not answer her complaint questions.
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.