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
Decisions 3,622 Stats Themes 15 By Organisation 40
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Showing 13 results matching "London Ambulance Service NHS Trust"

A practice in the Redbridge area (P-004963)
NHS in England Not Upheld
Report · Decision date: 2 Mar 2026
Treatment Treatment
AI summary: Mr K complained the Practice failed to act on his wife's worsening condition, prescribing unsuitable medication and failing to follow up. He also complained about ambulance delays and incorrect categorisation by the London Ambulance Service.
London Ambulance Service NHS Trust (P-004888)
NHS in England Not Upheld
Report · Decision date: 24 Feb 2026 · London Ambulance Service NHS Trust
Access Access Communication Transfer, discharge and aftercare
AI summary: Mrs C complained the Trust incorrectly prioritised her father's 999 call, delayed dispatching an ambulance, gave inaccurate ETA information, and didn't take him to a major trauma centre.
London Ambulance Service NHS Trust (P-004266)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 14 Nov 2025 · London Ambulance Service NHS Trust
Access
AI summary: Mrs O complained London Ambulance Service NHS Trust incorrectly triaged her sister on three occasions (999, 111, GP call), failing to send an ambulance, which she believes led to her sister dying alone.
London Ambulance Service NHS Trust (P-003815)
NHS in England Not Upheld
Report · Decision date: 20 Aug 2025 · London Ambulance Service NHS Trust
Diagnosis Drugs / medication Tests
AI summary: Mr L complained the Ambulance Service failed to recognize his mother's stroke symptoms, and the Hospital Trust delayed her assessment and transfer, contributing to her death.
London Ambulance Service NHS Trust (P-003492)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 31 Mar 2025 · London Ambulance Service NHS Trust
Diagnosis
AI summary: Miss U complained a paramedic's inadequate assessment of her stabbed son led to an incorrect hospital transfer delay, possibly affecting his outcome and contributing to his death.
London Ambulance Service NHS Trust (P-003399)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 30 Mar 2025 · London Ambulance Service NHS Trust
Administration Complaint handling
AI summary: Miss Y complained the Trust incorrectly categorised a 999 call, causing an ambulance delay that led to her father's avoidable death, and later withdrew a compensation offer.
London Ambulance Service NHS Trust (P-003271)
NHS in England Not Upheld
Report · Decision date: 30 Jan 2025 · London Ambulance Service NHS Trust
Treatment Access Communication Staffing levels
AI summary: Miss T complained the Trust incorrectly categorised her son's emergency calls, causing ambulance delays. She believed earlier arrival could have prevented cardiac arrest and saved his life.
London Ambulance Service NHS Trust (P-002829)
NHS in England Not Upheld
Report · Decision date: 31 Jul 2024 · London Ambulance Service NHS Trust
Access
AI summary: Mrs B complained the London Ambulance Service delayed answering her 999 call and ambulance arrival for her husband's heart attack, potentially impacting his survival.
London Ambulance Service NHS Trust (P-002407)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 25 Jan 2024 · London Ambulance Service NHS Trust
Confidentiality, privacy and safeguarding Confidentiality, privacy and safeguarding Confidentiality, privacy and safeguarding Confidentiality, privacy and safeguarding Confidentiality, privacy and safeguarding
AI summary: Mr L complained NHS 111 wrongly made a safeguarding referral for neglect, leading to social services involvement, harassment, and an unrequested paramedic visit.
London Ambulance Service NHS Trust (P-002374)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 5 Dec 2023 · London Ambulance Service NHS Trust
Access
AI summary: Mrs I complained about a three-hour ambulance delay for her father's stroke symptoms. She alleged this caused him to miss vital treatment, resulting in severe paralysis, aphasia, and memory loss.
London Ambulance Service NHS Trust (P-002251)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 31 Oct 2023 · London Ambulance Service NHS Trust
Access
AI summary: Mr B complained about severe delays and incorrect categorization of his wife's 999 call, leading to a prolonged ambulance wait and impacting her subsequent hospital treatment.
London Ambulance Service NHS Trust (P-001937)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 11 Apr 2023 · London Ambulance Service NHS Trust
Treatment Communication Access
AI summary: Mr X complained the ambulance arrived too late for his brother, who subsequently died, alleging the Trust should have sent help sooner.
London Ambulance Service NHS Trust (P-001391)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 24 May 2022 · London Ambulance Service NHS Trust
Access
AI summary: Ms R complained the London Ambulance Service failed to recognise her critically ill father, causing a significant delay in hospitalisation and denying him recovery, along with delayed and insufficient complaint responses.
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.

# Organisation Received Trend Decisions Upheld Partly Upheld Rate vs avg Remedy
Compliance
1 Child Maintenance Service 432 5 4 1 100% +27pp —
2 University Hospitals of North Midlands NHS Trust 136 6 3 3 100% +27pp —
3 United Lincolnshire Hospitals NHS Trust 129 11 3 8 100% +27pp —
4 East Kent Hospitals University NHS Foundation Trust 121 7 4 3 100% +27pp —
5 East Suffolk and North Essex NHS Foundation Trust 108 9 3 6 100% +27pp —
6 Ashford and St Peter's Hospitals NHS Foundation Trust 78 6 — 6 100% +27pp —
7 York and Scarborough Teaching Hospitals NHS Foundation Trust 76 7 2 5 100% +27pp —
8 Surrey and Sussex Healthcare NHS Trust 73 5 1 4 100% +27pp —
9 Croydon Health Services NHS Trust 70 6 — 6 100% +27pp —
10 Gateshead Health NHS Trust 69 5 3 2 100% +27pp —
11 University Hospitals Birmingham NHS Foundation Trust 339 26 12 12 92% +19pp —
12 University Hospitals Sussex NHS Foundation Trust 214 10 2 7 90% +17pp —
13 Northern Care Alliance NHS Foundation Trust 178 10 1 8 90% +17pp —
14 Department for Work and Pensions 853 9 3 5 89% +16pp —
15 UK Visas and Immigration 193 8 4 3 88% +15pp —
16 University Hospitals Dorset NHS Foundation Trust 108 7 — 6 86% +13pp —
17 University Hospitals Coventry and Warwickshire NHS Trust 159 12 3 7 83% +10pp —
18 County Durham and Darlington NHS Foundation Trust 94 12 4 6 83% +10pp —
19 Royal Wolverhampton NHS Trust 83 6 2 3 83% +10pp —
20 Cambridge University Hospitals NHS Foundation Trust 81 6 4 1 83% +10pp —
21 North Middlesex University Hospital NHS Trust 76 6 1 4 83% +10pp —
22 Barts Health NHS Trust 254 10 4 4 80% +7pp —
23 Royal Devon University Healthcare Foundation Trust 136 5 1 3 80% +7pp —
24 University Hospital Southampton NHS Foundation Trust 83 5 1 3 80% +7pp —
25 NORTH WEST ANGLIA NHS FOUNDATION TRUST 74 5 1 3 80% +7pp —
26 NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST 65 5 2 2 80% +7pp —
27 The Hillingdon Hospitals NHS Foundation Trust 65 5 3 1 80% +7pp —
28 Royal United Hospitals Bath NHS Foundation Trust 34 5 3 1 80% +7pp —
29 Royal Free London NHS Foundation Trust 269 9 2 5 78% +5pp —
30 MID Yorkshire Teaching NHS Trust 132 13 5 5 77% +4pp —
31 Manchester University NHS Foundation Trust 320 20 5 10 75% +2pp —
32 Mid and South Essex NHS Foundation Trust 267 14 4 6 71% -2pp —
33 University Hospitals of Derby and Burton NHS Foundation Trust 113 7 2 3 71% -2pp —
34 Portsmouth Hospitals NHS Trust 74 7 2 3 71% -2pp —
35 Lewisham and Greenwich NHS Trust 119 10 4 3 70% -3pp —
36 Lancashire Teaching Hospitals NHS Foundation Trust — — 10 2 5 70% -3pp —
37 HM Courts & Tribunals Service 830 6 2 2 67% -6pp —
38 King's College Hospital NHS Foundation Trust 194 6 2 2 67% -6pp —
39 Leeds Teaching Hospitals NHS Trust 158 9 4 2 67% -6pp —
40 Chelsea and Westminster Hospital NHS Foundation Trust 120 6 2 2 67% -6pp —
All-organisation benchmark 73% —

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.