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 29 results matching "County Durham and Darlington NHS Foundation Trust"
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.
County Durham and Darlington NHS Foundation Trust (P-004715)
NHS in England
Upheld
Risk assessment
Drugs / medication
Referral
Treatment
Communication
Complaint handling
Communication
AI summary: Ms U complained her father received inadequate assessment, leading to a preventable fall and injury, and cited delayed medication and poor communication regarding his deterioration and impending death.
County Durham and Darlington NHS Foundation Trust (P-004387)
NHS in England
Closed After Initial Enquiries
Treatment
Tests
AI summary: Mrs O complained the District Nursing team neglected her mother's hygiene, failed to report concerns or symptoms of organ failure, and didn't collect samples, contributing to her mother's death.
County Durham and Darlington NHS Foundation Trust (P-004212)
NHS in England
Closed After Initial Enquiries
Choice and Consent
AI summary: Mr R alleged the Trust wrongly kept his mother in hospital for a non-life-threatening condition, which he believes led to her deterioration and death.
County Durham and Darlington NHS Foundation Trust (P-003806)
NHS in England
Partly Upheld
Referral
AI summary: Ms M complained the Trust delayed a referral and funding application for her son to see an eating specialist, causing significant distress and a long-term detrimental impact.
County Durham and Darlington NHS Foundation Trust (P-003703)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs A complained about inadequate medical and midwifery care, including lack of support for bleeding and a doctor refusing examination, before and after her son's birth.
County Durham and Darlington NHS Foundation Trust (P-003409)
NHS in England
Not Upheld
Diagnosis
Diagnosis
AI summary: Mrs H complained both the Trust and her GP failed to timely investigate her stomach pain and weight loss, delaying her cancer diagnosis and causing prolonged suffering.
County Durham and Darlington NHS Foundation Trust (P-003367)
NHS in England
Upheld
Treatment
Nursing care
Referral
Diagnosis
Nursing care
AI summary: Mr O complained the Trust discharged his father-in-law without diagnosis, caused preventable pressure sores, made incorrect specialist referrals, and failed to diagnose a spinal stroke.
County Durham and Darlington NHS Foundation Trust (P-003322)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: The Trust allegedly provided no clear diagnosis or treatment for Dr V's CRPS, made him feel ignored, and handled his complaint poorly, causing chronic pain and distress.
County Durham and Darlington NHS Foundation Trust (P-003054)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr K complained the Trust failed to perform an ultrasound scan and administered anticoagulant medications without checking for internal bleeding, believing these actions hastened his wife's death.
County Durham and Darlington NHS Foundation Trust (P-003094)
NHS in England
Closed After Initial Enquiries
End of life care
Nursing care
Complaint handling
AI summary: Mrs A complained a DNAR order was placed on her brother without family input, staff made inappropriate comments, IV fluids were not changed, and a sponge for dry lips was refused, causing suffering and hastening death.
County Durham and Darlington NHS Foundation Trust (P-003026)
NHS in England
Closed After Initial Enquiries
Administration
AI summary: The Trust included false and damaging information about her in her daughter’s cognitive assessment report, causing mental health deterioration, a suicide attempt, and separation from her daughter.
County Durham and Darlington NHS Foundation Trust (P-003078)
NHS in England
Partly Upheld
Treatment
Nursing care
End of life care
AI summary: Her husband was pressured into an EBUS procedure despite being unfit. Nursing staff failed to identify his deterioration, and his wishes for discharge as a terminally ill patient were ignored.
County Durham and Darlington NHS Foundation Trust (P-002950)
NHS in England
Partly Upheld
Referral
End of life care
Communication
Diagnosis
Nursing care
AI summary: Mrs U complained about poor communication, lack of an overarching care plan, unmet nutrition/hydration needs, and delayed palliative care for her father.
County Durham and Darlington NHS Foundation Trust (P-003002)
NHS in England
Partly Upheld
Transfer, discharge and aftercare
Treatment
AI summary: Ms K complained the Trust inappropriately transferred her father while he was too unwell and then failed to provide necessary treatment, causing his condition to deteriorate and leading to his death.
County Durham and Darlington NHS Foundation Trust (P-002902)
NHS in England
Closed After Initial Enquiries
Treatment
Treatment
Communication
Referral
AI summary: Mrs G complained about her husband's hospital care, including medication dosage, inadequate respiratory treatment, a DNACPR order, and poor communication. She also cited a delayed referral.
County Durham and Darlington NHS Foundation Trust (P-002843)
NHS in England
Closed After Initial Enquiries
Administration
Communication
Access
Complaint handling
AI summary: Mrs U complained about unprofessional emergency department staff, including incorrect symptom transcription, not being listened to, discussing private matters, repeated tests, and long waits without adequate pain relief.
County Durham and Darlington NHS Foundation Trust (P-002696)
NHS in England
Not Upheld
Risk assessment
Treatment
Communication
Transfer, discharge and aftercare
Treatment
AI summary: Mrs E complained the Trust failed to prevent a fall, provide sufficient pain relief, give clear prognosis information, and had flawed discharge planning, leading to Mrs D's death.
County Durham and Darlington NHS Foundation Trust (P-002588)
NHS in England
Partly Upheld
Treatment
AI summary: Mrs T complained her father received inadequate food and drink, lacked mobility efforts, and had poor record keeping, contributing to his declining condition and death.
County Durham and Darlington NHS Foundation Trust (P-002654)
NHS in England
Closed After Initial Enquiries
End of life care
Communication
AI summary: Miss G complained the Trust inappropriately gave her mother end-of-life medication and recorded a DNACPR without family consent, believing it caused her mother's death.
County Durham and Darlington NHS Foundation Trust (P-003311)
NHS in England
Partly Upheld
Choice and Consent
AI summary: Mrs E complained her surgeon failed to warn her about the permanent loss of sensation following a hysterectomy, causing distress and impacting her ability to cope and work.
County Durham and Darlington NHS Foundation Trust (P-002451)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Drugs / medication
Record keeping and management
Record keeping and management
Communication
Death, mortuary and post-mortem arrangements
Complaint handling
Drugs / medication
Communication
AI summary: Mrs H complained her nil-by-mouth father-in-law was given oral medication, missed Parkinson's medication, suffered poor record-keeping, and poor communication, contributing to his death.
County Durham and Darlington NHS Foundation Trust (P-002052)
NHS in England
Closed After Initial Enquiries
Risk assessment
Surgery
COVID-19
Communication
AI summary: Mr I complained the Trust delayed his mother's hip surgery, discussed risks without family present, restricted visits, and notified him of her death by text message.
County Durham and Darlington NHS Foundation Trust (P-001905)
NHS in England
Closed After Initial Enquiries
Administration
Referral
Referral
Treatment
Treatment
AI summary: Miss O complained a practice misdiagnosed pelvic pain, delaying treatment for infection and causing infertility. She also cited a Trust secretary's error delaying a laparoscopy.
County Durham and Darlington NHS Foundation Trust (P-001785)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr A complained the Trust inappropriately discharged him twice without diagnosing his heart failure, leading to a missed opportunity for earlier treatment. He also complained about handling.
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.