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 15 results matching "Croydon Health Services NHS Trust"
Croydon Health Services NHS Trust (P-005021)
NHS in England
Closed After Initial Enquiries
Treatment
Nursing care
AI summary: Mr U complained about the lack of a secretion management plan for his mother, failure to re-refer her to physiotherapy, and poor response to her call bell.
Croydon Health Services NHS Trust (P-004991)
NHS in England
Partly Upheld
Treatment
Drugs / medication
Diagnosis
AI summary: Mr P complained about inappropriate advice, continued insulin, delayed diagnosis, and inadequate treatment for his wife at the Trust, leading to her death.
Croydon Health Services NHS Trust (P-004936)
NHS in England
Partly Upheld
Tests
Communication
AI summary: Miss Y alleged the Trust dismissed her concerns during premature labour, leading to her son's health issues and her own psychological distress.
Croydon Health Services NHS Trust (P-004529)
NHS in England
Closed After Initial Enquiries
Administration
AI summary: Ms N complained about a locum's failure to examine her and provide correct information, poor appointment handling, and the Trust's inadequate complaint resolution.
Croydon Health Services NHS Trust (P-003774)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
Complaint handling
AI summary: Mrs J complained the Trust discharged her sister-in-law without a care package or involving relatives, forcing her to pay for private care after breaking her arm.
Croydon Health Services NHS Trust (P-003427)
NHS in England
Partly Upheld
COVID-19
COVID-19
Nursing care
Drugs / medication
Communication
AI summary: Mr H alleged the Trust failed to provide his mother with adequate nutrition and proper diabetes control, including medication errors, which he believes hindered her recovery and cancer treatment.
Croydon Health Services NHS Trust (P-003176)
NHS in England
Closed After Initial Enquiries
Diagnosis
Treatment
Communication
Treatment
AI summary: The Trust failed to recognise her mother's serious condition, provide appropriate care, keep the family informed, and gave a wrong diagnosis, leading to her mother's death alone.
Croydon Health Services NHS Trust (P-003129)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Ms G complained the Trust failed to recognise the severity of B's illness, took too long to treat and escalate care, and did not listen to her concerns about sepsis.
Croydon Health Services NHS Trust (P-003158)
NHS in England
Closed After Initial Enquiries
Treatment
Treatment
AI summary: Ms P complained about her father's care at two Trusts, citing poor dialysis, lack of food/drink, inadequate communication, and two falls, which she believed contributed to his death.
Croydon Health Services NHS Trust (P-002643)
NHS in England
Closed After Initial Enquiries
Hospital acquired infection / healthcare-associated infection
Drugs / medication
Drugs / medication
Tests
Diagnosis
AI summary: Mrs L complained the Trust failed to keep her husband isolated, withheld diabetes medication and antibiotics, and cancelled a lung drainage procedure, contributing to his death from pneumonia.
Croydon Health Services NHS Trust (P-002593)
NHS in England
Partly Upheld
Communication
End of life care
AI summary: Miss A complained the Trust failed to inform her mother's cancer was terminal and provided poor end-of-life care, specifically inadequate pain relief.
Croydon Health Services NHS Trust (P-002427)
NHS in England
Closed After Initial Enquiries
Nursing care
Treatment
AI summary: Mrs R complained Croydon Health Services NHS Trust did not provide appropriate pain relief, and about poor staff behaviour and the discharge process after surgery.
Croydon Health Services NHS Trust (P-001957)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr G complained the Trust's decision to stop his sister's antibiotics despite working blood results caused her death, questioning the ethical and legal basis of the decision.
Croydon Health Services NHS Trust (P-001374)
NHS in England
Partly Upheld
Nursing care
AI summary: Mr N complained the Trust's district nurses failed to administer his mother's medication, which he believes led to her seizure and death.
Croydon Health Services NHS Trust (P-001265)
NHS in England
Partly Upheld
Diagnosis
AI summary: Ms L complained doctors failed to identify and treat infections and sepsis in her father, leading to an avoidable death. She disputed the Trust's lymphoma diagnosis and suspected a cover-up.
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.