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 "Gloucestershire Hospitals NHS Foundation Trust"
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.
Gloucestershire Hospitals NHS Foundation Trust (P-004780)
NHS in England
Closed After Initial Enquiries
Diagnosis
Access
Diagnosis
Access
AI summary: Ms C complained the Trust failed to properly investigate and treat the cause of her abdominal pain, fainting, high blood pressure and haemorrhaging between April 2021 and September 2023.
Gloucestershire Hospitals NHS Foundation Trust (P-004158)
NHS in England
Partly Upheld
Referral
Treatment
Treatment
AI summary: Miss G complained about a lack of nurse escalation, surgical review, and delayed treatment for her father, Mr G, after he deteriorated, leading to his death.
Gloucestershire Hospitals NHS Foundation Trust (P-003916)
NHS in England
Closed After Initial Enquiries
Treatment
Communication
Record keeping and management
Complaint handling
AI summary: Mrs T complained the Trust failed to holistically assess and monitor her mother, did not engage her on a RESPECT form, poorly documented care, and communicated poorly, contributing to her death. She also complained about the Trust's poor complaint handling.
Gloucestershire Hospitals NHS Foundation Trust (P-003777)
NHS in England
Partly Upheld
Access
Complaint handling
AI summary: Mr S complained the Trust failed to provide help as his chest pain deteriorated in the ED waiting room. He also complained the Trust failed to supply requested CCTV footage.
Gloucestershire Hospitals NHS Foundation Trust (P-003772)
NHS in England
Closed After Initial Enquiries
Referral
Surgery
AI summary: Mr F complained two Trusts delayed his urgent heart operation for over six weeks, causing significant stress, anxiety, PTSD, and physical complications.
Gloucestershire Hospitals NHS Foundation Trust (P-003465)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Treatment
Diagnosis
AI summary: Mrs E complained the Trust and Practice failed to act on allergic reactions to medication, monitor cortisol levels, address concerns about injections, and disclose her daughter's heart condition, contributing to her death.
Gloucestershire Hospitals NHS Foundation Trust (P-003337)
NHS in England
Closed After Initial Enquiries
Referral
Treatment
Tests
AI summary: A surgeon failed to investigate Miss A's rectal prolapse, another refused contingency options, and the Trust failed to act on blood tests, impacting her quality of life.
Gloucestershire Hospitals NHS Foundation Trust (P-003187)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Ms U complained the Trust failed to diagnose and treat her parasitic head infection, causing ongoing uncomfortable symptoms such as pain, exhaustion, and heart arrhythmia.
Gloucestershire Hospitals NHS Foundation Trust (P-003030)
NHS in England
Closed After Initial Enquiries
Diagnosis
Communication
AI summary: Ms A complained a consultant misdiagnosed a dislocated kneecap, failed to examine her knee, and dismissed her pain as psychological, leading to prolonged suffering and necessary surgery.
Gloucestershire Hospitals NHS Foundation Trust (P-002691)
NHS in England
Upheld
Record keeping and management
Treatment
Record keeping and management
Treatment
AI summary: Miss F complained the Trust failed to record/communicate about her father's restraint and discharged him without treating constipation or urine retention, contributing to his death.
Gloucestershire Hospitals NHS Foundation Trust (P-002430)
NHS in England
Closed After Initial Enquiries
Communication
Record keeping and management
Drugs / medication
AI summary: Mrs O complained about inadequate pain relief, unheeded concerns, and failure to offer induction during labour, along with an incorrect birth time, causing a traumatic birth experience.
Gloucestershire Hospitals NHS Foundation Trust (P-002292)
NHS in England
Closed After Initial Enquiries
Communication
Diagnosis
Choice and Consent
AI summary: Trust failed to follow Mr I's advance decision, misdiagnosed a seizure as a fall, and shared his health information with the DVLA without consent.
Gloucestershire Hospitals NHS Foundation Trust (P-001659)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Mrs H complained a radiologist consultant failed to identify epidural thoracic disease in Mr H's vertebra in March 2021, leading to severe pain and permanent nerve damage.
Gloucestershire Hospitals NHS Foundation Trust (P-001350)
NHS in England
Not Upheld
Tests
Treatment
Treatment
AI summary: Mr O complained that Gloucestershire Hospitals NHS Foundation Trust failed to investigate his worsening arthritic pain during ED visits and specialist appointments, leading to a life-threatening fluid build-up.
Gloucestershire Hospitals NHS Foundation Trust (P-001250)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Diagnosis
Communication
Nursing care
Record keeping and management
AI summary: Mr A complained GPs failed to recognise his son's pneumonia deterioration and about lost blood tests and inadequate care by an MS Specialist Nurse. He also complained about medication changes not being discussed and inappropriate staff behaviour.
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.