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 14 results matching "North West Ambulance Service NHS Trust"

North West Ambulance Service NHS Trust (P-004337)
NHS in England Not Upheld
Report · Decision date: 25 Nov 2025 · North West Ambulance Service NHS Trust
Treatment
AI summary: Miss A complained the Trust failed to identify the cause of her mother's condition or provide appropriate treatment, such as an ECG and immediate hospital transfer, to prevent a cardiac arrest.
North West Ambulance Service NHS Trust (P-003534)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 28 May 2025 · North West Ambulance Service NHS Trust
Access
AI summary: Mrs J complained about a long ambulance waiting time (1 hour 45 minutes) for her seriously ill husband, which she believes delayed treatment and contributed to his death.
North West Ambulance Service NHS Trust (P-003400)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 27 Mar 2025 · North West Ambulance Service NHS Trust
Access
AI summary: Mrs E complained the Trust incorrectly categorised 999 calls, provided wrong ambulance wait times, and advised her to take her husband to A&E, leading to treatment delays and his death.
North West Ambulance Service NHS Trust (P-003319)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 11 Feb 2025 · North West Ambulance Service NHS Trust
Treatment
AI summary: Mr O complained a paramedic failed to recognise his father, Mr W, needed urgent treatment, causing a 14-hour ambulance delay. He believes this delay led to his father's death from pneumonia.
North West Ambulance Service NHS Trust (P-003239)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 17 Dec 2024 · North West Ambulance Service NHS Trust
Treatment Treatment
AI summary: Mrs L complained NWAS left her mother on a trolley for over 30 hours without adequate care, moved her with a fractured pelvis, and the Trust failed to monitor falls risk, leading to a fall.
North West Ambulance Service NHS Trust (P-003108)
NHS in England Partly Upheld
Report · Decision date: 11 Nov 2024 · North West Ambulance Service NHS Trust
Diagnosis Complaint handling
AI summary: Miss R complained the Trust failed to deliver CPR for 11 minutes when her sister was in peri-arrest, missing an opportunity for survival, and did not comply with recommendations.
North West Ambulance Service NHS Trust (P-002774)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 8 Jul 2024 · North West Ambulance Service NHS Trust
Communication
AI summary: The Trust's 111 service allegedly mishandled her son's call, which Mrs S believes contributed to his death.
North West Ambulance Service NHS Trust (P-002281)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 30 Nov 2023 · North West Ambulance Service NHS Trust
None
AI summary: Mr U complained the Trust repeatedly failed to transport his mother to hospital due to poor risk assessments. He alleged this caused her pain, deterioration, mental distress, and contributed to her death.
North West Ambulance Service NHS Trust (P-002026)
NHS in England Not Upheld
Report · Decision date: 22 Jun 2023 · North West Ambulance Service NHS Trust
None None Treatment
AI summary: Paramedics failed to properly assess his father after a fall, focusing on opioid use and missing potential neck/back fractures, limiting treatment options.
North West Ambulance Service NHS Trust (P-001730)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 19 Jan 2023 · North West Ambulance Service NHS Trust
Diagnosis
AI summary: Mr I complained a paramedic misdiagnosed his fall injuries as pulled muscles, delaying appropriate treatment and leaving him with lasting pain and mobility problems.
North West Ambulance Service NHS Trust (P-001508)
NHS in England Closed After Initial Enquiries
Statement · Decision date: 11 Aug 2022 · North West Ambulance Service NHS Trust
Access Access Access
AI summary: Mr B complained the ambulance service failed to send an ambulance for his partner, Miss L, or properly assess her, which he believes led to her death.
North West Ambulance Service NHS Trust (P-001421)
NHS in England Upheld
Report · Decision date: 7 Jun 2022 · North West Ambulance Service NHS Trust
Access Communication
AI summary: Mrs O complained the 999 call for her father was incorrectly triaged, an ambulance was not sent, and inaccurate information about arrival times was given, potentially delaying treatment and contributing to his death.
North West Ambulance Services NHS Trust (P-001387)
NHS in England Partly Upheld
Report · Decision date: 18 May 2022 · North West Ambulance Service NHS Trust
Diagnosis Treatment
AI summary: Mr O complained ambulance crew failed to appropriately assess and immobilise his neck after a fall, contributing to his injury.
North West Ambulance Service NHS Trust (P-001051)
NHS in England Upheld
Report · Decision date: 6 Apr 2021 · North West Ambulance Service NHS Trust
Diagnosis Treatment Treatment Referral
AI summary: Miss A complained the ambulance service incorrectly categorised her father's 999 call, delayed adrenaline treatment, and failed to use a defibrillator promptly, leading to his 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.

# 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.