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 16 results matching "Dartford and Gravesham NHS Trust"
Dartford and Gravesham NHS Trust (P-005096)
NHS in England
Partly Upheld
Diagnosis
AI summary: Mrs X complained her father was not informed about a lung mass, was given incorrect information about cancer, experienced delays in testing, and was not informed he was dying.
Dartford and Gravesham NHS Trust (P-004430)
NHS in England
Closed After Initial Enquiries
Nursing care
Nursing care
Treatment
Nursing care
Nursing care
AI summary: A daughter complained her father received inadequate nutrition and fluids, delayed feeding tube insertion, poor supervision, and insufficient toileting assistance across multiple wards.
An independent provider in the Tonbridge and Malling area (P-004348)
NHS in England
Partly Upheld
Referral
Diagnosis
Communication
Referral
Transfer, discharge and aftercare
AI summary: Mrs A complained the Trust delayed her husband's cancer diagnosis, wrongly discharged him as medically fit, and did not follow recommendations, causing suffering before his death.
Dartford and Gravesham NHS Trust (P-004178)
NHS in England
Closed After Initial Enquiries
Access
Communication
AI summary: Mrs A complained the Trust delayed allergy testing, blood tests, and scans for her child, miscommunicated sepsis, and mishandled feeding and specialist referrals.
Dartford and Gravesham NHS Trust (P-004244)
NHS in England
Closed After Initial Enquiries
Drugs / medication
AI summary: Mr D complained the Trust administered a medication on 9 September that led to his mother’s sudden death, causing his father and him immense distress.
Dartford and Gravesham NHS Trust (P-003767)
NHS in England
Partly Upheld
Treatment
AI summary: Mrs B complained the Trust failed to take timely action after her husband's CT scan identified a pulmonary embolism, delaying treatment and contributing to his death.
Dartford and Gravesham NHS Trust (P-003726)
NHS in England
Not Upheld
Drugs / medication
Treatment
AI summary: Ms A complained her mother received inappropriate medication and experienced delayed interventions for respiratory and kidney issues, which she believed contributed to her death.
Dartford and Gravesham NHS Trust (P-002888)
NHS in England
Closed After Initial Enquiries
End of life care
Administration
Drugs / medication
Drugs / medication
AI summary: Mr R complained his mother was placed on end-of-life care, denied food/water, had her hearing aid lost, diabetes medication stopped, and wrongly given certain medications, which he believes led to her death.
Dartford and Gravesham NHS Trust (P-002771)
NHS in England
Closed After Initial Enquiries
Charges
AI summary: Ms W complained the Trust charged her for pregnancy tests without warning or consent, contrary to Overseas Visitors rules, potentially impacting her visa status.
Dartford and Gravesham NHS Trust (P-002712)
NHS in England
Partly Upheld
Diagnosis
Treatment
AI summary: Mrs O's husband complained the Trust failed to diagnose her condition and provide appropriate care across five admissions, which he believed led to her premature death.
Dartford and Gravesham NHS Trust (P-002583)
NHS in England
Closed After Initial Enquiries
End of life care
Transfer, discharge and aftercare
Treatment
AI summary: Ms F complained about multiple Trusts, alleging her father was prematurely masked, unnecessarily ventilated, transferred worsening his condition, received poor care, and died prematurely.
Dartford and Gravesham NHS Trust (P-002600)
NHS in England
Closed After Initial Enquiries
Access
Drugs / medication
AI summary: Mrs H complained the Trust repeatedly delayed her priority hip replacement surgery, failed to provide pain relief, and refused transfers, causing severe pain and forcing private surgery.
Dartford and Gravesham NHS Trust (P-002347)
NHS in England
Closed After Initial Enquiries
Diagnosis
Diagnosis
AI summary: Mrs H complained Trust A missed diagnosing O with beta thalassaemia during antenatal testing and after birth. Trust B then failed to diagnose O, causing distress and unnecessary treatment.
Dartford and Gravesham NHS Trust (P-001816)
NHS in England
Closed After Initial Enquiries
None
None
Communication
AI summary: Mrs O complained King's College Trust failed to refer her father to A&E, and D&G Trust inappropriately discharged him and failed to communicate his deteriorating condition.
Dartford and Gravesham NHS Trust (P-001598)
NHS in England
Closed After Initial Enquiries
None
AI summary: Ms K complained the Trust misdiagnosed a womb polyp as a fibroid, leading to incorrect treatment, delayed removal, significant blood loss, and distress.
South East Coast Ambulance Service NHS Foundation Trust (P-001224)
NHS in England
Upheld
Treatment
Treatment
Complaint handling
Nursing care
Other - Health
Complaint handling
Diagnosis
Treatment
AI summary: Ms E complained the ambulance crew misdiagnosed her injury and inadequately assessed pain. She also complained hospital staff failed to diagnose a fracture, roughly applied a splint, and refused toilet assistance.
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.