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 37 results matching "Guy's and St Thomas' NHS Foundation Trust"
Guy's and St Thomas' NHS Foundation Trust (P-004974)
NHS in England
Closed After Initial Enquiries
Choice and Consent
Diagnosis
Communication
AI summary: Mr A complained the Trust failed to adequately involve him regarding his child's autism assessment, incorrectly decided to conduct it during a stressful period, and failed to adequately consult him throughout the process.
Guy's and St Thomas' NHS Foundation Trust (P-004893)
NHS in England
Closed After Initial Enquiries
Diagnosis
Diagnosis
AI summary: Ms P complained the Trust failed to identify endometriosis in a 2020 MRI, didn't investigate it properly between 2023, and misdiagnosed IBS.
Guy's and St Thomas' NHS Foundation Trust (P-004753)
NHS in England
Closed After Initial Enquiries
Treatment
Complaint handling
AI summary: Mrs O complained about her brother's discharge, including being discharged before he was fit, lack of assessments/referrals, and a delayed complaint response from Guy's and St Thomas' NHS Foundation Trust.
Guy's and St Thomas' NHS Foundation Trust (P-004749)
NHS in England
Not Upheld
Treatment
AI summary: Mr A complained his wife was not informed about dry mouth/mucus build-up risks with her NIV or given a humidifier sooner, leading to a fatal choking incident.
Guy's and St Thomas' NHS Foundation Trust (P-004706)
NHS in England
Closed After Initial Enquiries
Communication
Diagnosis
AI summary: Miss U complained the Trust failed to inform her mother of cancer recurrence symptoms and inadequately monitored her, causing delayed detection of secondary cancer and her death.
Guy's and St Thomas' NHS Foundation Trust (P-004608)
NHS in England
Closed After Initial Enquiries
Treatment
Administration
AI summary: Mrs S complained the Trust declined her request for laser treatment for a lesion on her cheek and took too long to respond to her emails. She suffered considerable distress due to the lack of treatment and delays.
Guy's and St Thomas' NHS Foundation Trust (P-004565)
NHS in England
Closed After Initial Enquiries
Diagnosis
Diagnosis
AI summary: Miss U complains that two Trusts failed to timely diagnose her cancer between 2018 and 2022, leading to a stage four diagnosis and more invasive treatment.
Guy's and St Thomas' NHS Foundation Trust (P-004466)
NHS in England
Closed After Initial Enquiries
Communication
Referral
Transfer, discharge and aftercare
Treatment
Treatment
AI summary: Mr W complained the Trust failed to properly manage his wife's discharge, including inadequate communication and lack of referrals, which he believes led to her condition deteriorating and death.
Guy's and St Thomas' NHS Foundation Trust (P-004352)
NHS in England
Closed After Initial Enquiries
Surgery
Choice and Consent
AI summary: The Trust changed Mrs N's breast surgery plan on the day, pressuring her into a different outcome, causing distress and needing further surgery.
Guy's and St Thomas' NHS Foundation Trust (P-004301)
NHS in England
Closed After Initial Enquiries
Administration
Administration
Administration
Administration
AI summary: Mr E complained the Trust failed to act on safeguarding concerns he raised about his mother's care home, lacked appropriate procedures, and did not investigate his concerns.
Barts Health NHS Trust (P-004245)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
Transfer, discharge and aftercare
AI summary: Mrs V complained her father developed sepsis due to poor infection control at GST Trust, and Barts Trust's ACCESS service failed to connect his chest drain, contributing to his death.
Guy's and St Thomas' NHS Foundation Trust (P-004161)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mrs Y complained the Trust failed to arrange an interpreter, did not fully test for DPYD mutations, continued chemotherapy despite reactions, and delayed a CT scan for her brother.
Guy's and St Thomas' NHS Foundation Trust (P-003671)
NHS in England
Closed After Initial Enquiries
Diagnosis
Nursing care
Diagnosis
Nursing care
AI summary: Ms K complained a doctor failed to identify new spinal lesions on her mother's scan, leading to delayed cancer treatment and her mother's painful death.
Guy's and St Thomas' NHS Foundation Trust (P-003603)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Miss W complained the Trust failed to adequately check her grandmother at ED, missing a pulmonary embolism which resulted in her death. This caused distress and lack of closure.
Guy's and St Thomas' NHS Foundation Trust (P-003589)
NHS in England
Closed After Initial Enquiries
Hospital acquired infection / healthcare-associated infection
AI summary: Ms P complained she contracted hepatitis B from the Trust during surgery on March 19, 2024. This caused her anxiety, worthlessness, and loss of trust in the NHS.
Guy's and St Thomas' NHS Foundation Trust (P-003615)
NHS in England
Closed After Initial Enquiries
Access
Referral
AI summary: Ms R complained about insufficient appointments and the Trust's refusal to refer her for water therapy or osteopath services, causing considerable pain and distress.
Guy's and St Thomas' NHS Foundation Trust (P-003332)
NHS in England
Closed After Initial Enquiries
Tests
AI summary: Mr U complained the Trust failed to arrange a biopsy for a thyroid lump, citing its size and not considering his increased cancer risk from radiation exposure as a former operating department practitioner.
Guy's and St Thomas' NHS Foundation Trust (P-003369)
NHS in England
Closed After Initial Enquiries
Surgery
AI summary: Miss R complained that surgeons at Guy's and St Thomas' NHS Foundation Trust used an annuloplasty band that was too small during her mitral heart valve repair in 2018, causing further damage.
Guy's and St Thomas' NHS Foundation Trust (P-003259)
NHS in England
Closed After Initial Enquiries
Choice and Consent
Surgery
Diagnosis
Referral
AI summary: Mrs A complained about failures in consent, surgical performance, post-operative assessment, and referral by the Trust, leading to nerve paralysis and foot drop.
Guy's and St Thomas' NHS Foundation Trust (P-003165)
NHS in England
Closed After Initial Enquiries
Communication
AI summary: Mr L complained a physiotherapist failed to use two-person assistance to move his mother and lied about a fall, which he believed led to her becoming bedbound and developing pressure sores.
Guy's and St Thomas' NHS Foundation Trust (P-003079)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr P complained about a nurse's mishandling and improper reinsertion of his daughter's tube. He believed this caused her deterioration and avoidable death two days later, leading to extreme distress for his family.
Guy's and St Thomas' NHS Foundation Trust (P-003057)
NHS in England
Closed After Initial Enquiries
Surgery
AI summary: Mr S complained a consultant damaged his nerve during surgery in September 2021, resulting in permanent functional nerve damage to his hand, requiring further surgeries and impacting daily activities.
Guy's and St Thomas' NHS Foundation Trust (P-002892)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr R complained doctors did not inform him of his wife's terminal condition, used jargon, administered inappropriate chemotherapy, and prevented her from receiving treatment abroad, which he believes led to her death.
Guy's and St Thomas' NHS Foundation Trust (P-002806)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr C complained his late son was inappropriately discharged without IV diuretics, and readmitted with delayed IV diuretics, which Mr C believes caused his son's severe deterioration and death.
Guy's and St Thomas' NHS Foundation Trust (P-002683)
NHS in England
Closed After Initial Enquiries
Treatment
COVID-19
Nursing care
AI summary: The Trust failed to manage her daughter's deteriorating condition, did not administer a COVID-19 vaccination, and failed to arrange home nursing care, leading to suffering and death.
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.