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 23 results matching "The Dudley Group NHS Foundation Trust"
The Dudley Group NHS Foundation Trust (P-004885)
NHS in England
Closed After Initial Enquiries
Diagnosis
Treatment
AI summary: Ms C complained the Trust failed to review records promptly, listen to family concerns, consider all symptoms, and provide a suitable diagnosis and treatment for her father.
The Dudley Group NHS Foundation Trust (P-004778)
NHS in England
Closed After Initial Enquiries
Communication
AI summary: Mrs E complained the Trust stopped her podiatry treatment, offered no alternatives, and this caused pain, reduced mobility, and decline in mental health.
The Dudley Group NHS Foundation Trust (P-004708)
NHS in England
Not Upheld
Drugs / medication
Treatment
Communication
Record keeping and management
Treatment
End of life care
AI summary: Mrs X complained her husband received improper care, including delayed diagnosis, misinterpreted symptoms, poor communication, inappropriate end-of-life care, and an undignified death.
The Dudley Group NHS Foundation Trust (P-004695)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Miss H complained the Trust should have marked her father's lung function test as urgent, which she believes could have led to earlier medication and extended his life.
The Dudley Group NHS Foundation Trust (P-004544)
NHS in England
Closed After Initial Enquiries
Charges
AI summary: Ms A complained about The Dudley Group NHS Foundation Trust wrongly charging her £530 for an emergency department visit, alleging discrimination due to her health condition.
The Dudley Group NHS Foundation Trust (P-004232)
NHS in England
Not Upheld
Treatment
AI summary: Mrs A complained about inappropriate back pain management, delays in diagnosing a spinal fracture, unresponsiveness after morphine, and inappropriate hospital discharges for her father.
The Dudley Group NHS Foundation Trust (P-003580)
NHS in England
Closed After Initial Enquiries
Treatment
Communication
AI summary: Ms E complained the Trust delayed carbon dioxide tests, delaying non-invasive ventilation for her mother. She also alleged poor communication about stopping active treatment without family or her mother's consent.
The Dudley Group NHS Foundation Trust (P-003281)
NHS in England
Partly Upheld
Drugs / medication
Nursing care
AI summary: Miss A complained about medication mismanagement for her mother, including stopping essential drugs, incorrect dosages, and feeding despite aspiration risk, which she believed contributed to her death.
The Dudley Group NHS Foundation Trust (P-002997)
NHS in England
Partly Upheld
Treatment
AI summary: Mrs Y complained the Trust provided inadequate feeding assistance and mouth care, failed to safeguard an aspirin allergy, frequently changed feeding status, and made insensitive comments.
The Dudley Group NHS Foundation Trust (P-002624)
NHS in England
Upheld
Diagnosis
Treatment
AI summary: Mrs H complained the Trust failed to timely remove her mother's gallbladder despite severe pain, leading to her avoidable death from sepsis.
The Dudley Group NHS Foundation Trust (P-002565)
NHS in England
Closed After Initial Enquiries
Surgery
AI summary: Care after a caesarean section led to an infection and sepsis, requiring further surgery and causing a diagnosis of PTSD.
The Dudley Group NHS Foundation Trust (P-002498)
NHS in England
Closed After Initial Enquiries
Treatment
Transfer, discharge and aftercare
Administration
Treatment
AI summary: Ms I complained about her mother's hip replacement care, alleging errors in surgical decisions, poor discharge planning, lost clothes, and a hip dislocation during transfer, leading to health decline.
The Dudley Group NHS Foundation Trust (P-002306)
NHS in England
Closed After Initial Enquiries
None
None
AI summary: Mrs D complained her mother developed fatal pressure sores due to neglect, citing poor communication and frequent ward changes as contributing factors to her deteriorating health.
The Dudley Group NHS Foundation Trust (P-001767)
NHS in England
Closed After Initial Enquiries
Record keeping and management
AI summary: Mrs O complained The Dudley Group NHS Foundation Trust lost two of her mother's necklaces during her care, seeking £600 compensation for the loss.
The Dudley Group NHS Foundation Trust (P-001695)
NHS in England
Closed After Initial Enquiries
Drugs / medication
AI summary: Miss I complained about incorrect medication, delayed antibiotics, not allowing a relative to attend tests, problems during a swallowing test, and failure to perform a post-mortem on her grandmother.
The Dudley Group NHS Foundation Trust (P-001506)
NHS in England
Closed After Initial Enquiries
Administration
Communication
Communication
Communication
AI summary: Mrs O complained about staff incompetence, ignored concerns regarding her catheter and cannula, witnessed patient abuse, and breaches of patient privacy during her inpatient stay.
The Dudley Group NHS Foundation Trust (P-001468)
NHS in England
Not Upheld
None
None
None
AI summary: Miss K complained her mother was incorrectly discharged while unwell, then discharged to the wrong residential care setting, and received inadequate physiotherapy during her admissions.
The Dudley Group NHS Foundation Trust (P-001373)
NHS in England
Closed After Initial Enquiries
Communication
AI summary: Mr O complained that information about his heart rhythm after surgery was not shared correctly or timely, leading to a loss of trust in clinicians.
The Dudley Group NHS Foundation Trust (P-001329)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Nursing care
AI summary: Mrs O complained about her late husband's rapid deterioration in hospital, alleging incorrect Parkinson's medication, inadequate nutrition/fluid monitoring, and inappropriate use of continence pads.
The Dudley Group NHS Foundation Trust (P-001346)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Ms Z complained she developed a pulmonary embolism due to Depo-Provera injections provided by the Trust, leading to lifelong medication, distress, and worry about her health.
The Dudley Group NHS Foundation Trust (P-001301)
NHS in England
Upheld
Medical assessment
Complaint handling
AI summary: Miss E complained the Trust failed to act on Mr M's deteriorating symptoms, ignored an urgent MRI, and discharged him inappropriately. She also raised concerns about poor record keeping.
The Dudley Group NHS Foundation Trust (P-001289)
NHS in England
Partly Upheld
Drugs / medication
Treatment
AI summary: Daughter complained her mother's chronic diarrhoea and SIBO were not appropriately treated, and medication for Parkinson's, pain, and anxiety was incorrectly administered.
The Dudley Group NHS Foundation Trust (P-001070)
NHS in England
Partly Upheld
Diagnosis
AI summary: Mrs M complained there was a delay in diagnosing her father’s stroke and that morphine administration made subsequent assessment difficult, leading to a significant decline in his health.
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.