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
King's College Hospital NHS Foundation Trust (P-005139)
NHS in England
Closed After Initial Enquiries
Administration
AI summary: Mrs T complained the Trust lost her two gold rings due to incorrect procedures when recording and handling patient property, causing her stress.
Veterans UK (P-005141)
UK Government
Closed After Initial Enquiries
Pensions
AI summary: Mr E complained Veterans UK handled his asthma claim poorly, with delays transferring it and incorrect handling, causing him stress and impacting his mental health.
South Tees Hospitals NHS Foundation Trust (P-005138)
NHS in England
Closed After Initial Enquiries
Tests
Treatment
Nursing care
AI summary: Mr I complained about delays in diagnosing and treating his wife's infections, leading to her death, and inadequate nursing care on her last day.
Bradford Teaching Hospitals NHS Foundation Trust (P-005140)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Mrs A complained about delays in diagnosing her skin cancer due to cancelled appointments, leading to distress, discomfort, more complicated surgery, and nerve damage.
An independent provider in the Wealden area (P-005144)
NHS in England
Upheld
Disability
Complaint handling
AI summary: Miss L complained AJM Healthcare took too long to deliver a suitable wheelchair, failed to communicate, and did not collect the old one, impacting her health and finances; also the ICB did not investigate her complaint properly.
NHS England (P-005142)
NHS in England
Closed After Initial Enquiries
Continuing healthcare
AI summary: Mrs O complained about NHS England's decision to uphold the ICB's decision that her husband was not eligible for NHS Continuing Healthcare, causing him to pay for care costs.
Worcestershire Acute Hospitals NHS Trust (P-005143)
NHS in England
Partly Upheld
Referral
Tests
Drugs / medication
Treatment
AI summary: Mrs B complained about delays in arranging an MRI scan and inadequate care at the ED for her husband, leading to his death and preventing end-of-life decisions.
Essex Partnership University NHS Foundation Trust (P-005129)
NHS in England
Upheld
Access
Confidentiality, privacy and safeguarding
Choice and Consent
Communication
Nursing care
Complaint handling
AI summary: Miss B complained about the Trust's use of Oxevision without her consent or sufficient information, and staff relying on it instead of in-person observations, causing anxiety and a sense of vulnerability.
Manchester University NHS Foundation Trust (P-005128)
NHS in England
Upheld
Transfer, discharge and aftercare
Confidentiality, privacy and safeguarding
End of life care
Communication
Treatment
Choice and Consent
AI summary: Miss L and Miss N complained about inadequate supervision, inappropriate discharge, and lack of palliative care for their brother, leading to pain, distress, and impacting his death.
Child Maintenance Service (CMS) (P-005133)
UK Government
Closed After Initial Enquiries
Child maintenance
Child maintenance
Complaint handling
AI summary: Mr W complained about the CMS failing to follow the correct process for a DNA test, providing incorrect information, and mishandling his complaint, leading to stress and mental health issues.
Avon and Wiltshire Mental Health Partnership NHS Trust (P-005126)
NHS in England
Closed After Initial Enquiries
Transfer, discharge and aftercare
Transfer, discharge and aftercare
AI summary: Mr M complained about his sister Ms M's three inappropriate discharges and inadequate follow-on care, which he says led to suicide attempts and impacted the family.
A practice in the North Yorkshire area (P-005125)
NHS in England
Not Upheld
Administration
Access
Confidentiality, privacy and safeguarding
AI summary: Mr R complained the practice refused him an urgent GP consultation and failed to follow procedures for a mental health crisis, worsening his PTSD.
A practice in the Bedford area (P-005130)
NHS in England
Closed After Initial Enquiries
Treatment
Referral
Tests
Miss D complains about aspects of the care and treatment she received from the Practice between February and June 2025.
NHS Cheshire and Merseyside (P-005132)
NHS in England
Closed After Initial Enquiries
Continuing healthcare
Mr A complains NHS England’s (NHSE) independent review panel (IRP) upheld Cheshire and Merseyside Integrated Care Board’s (the ICB) decision that his mother, Mrs B was not eligible for NHS continuing healthcare (CHC) funding on 23 September 2022.
A dental practice in the Leeds area (P-005131)
NHS in England
Closed After Initial Enquiries
Treatment
Choice and Consent
Mr K complains about the care and treatment he received over several months from June 2025. He complains his crown fell out multiple times and he was not offered alternative treatments.
Sussex Partnership NHS Foundation Trust (P-005136)
NHS in England
Closed After Initial Enquiries
Access
Access
Miss L has raised concerns about the waiting times for an autism assessment and not being prioritised.
The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust (P-005134)
NHS in England
Closed After Initial Enquiries
Communication
Mr P complains about poor communication provided to his wife during her care and treatment for cancer. He complains that she was not told there was no cure for her cancer, why chemotherapy was stopped, and that appointments were cancelled with no explanations.
York and Scarborough Teaching Hospitals NHS Foundation Trust (P-005137)
NHS in England
Partly Upheld
Nursing care
Diagnosis
Transfer, discharge and aftercare
End of life care
AI summary: Miss B complained about inadequate pressure ulcer care, a missed MRI, delayed osteomyelitis treatment, inappropriate discharge, and misdiagnosed delirium for her mother.
Child Maintenance Service (CMS) (P-005135)
UK Government
Partly Upheld
Child maintenance
AI summary: Mr A complained the CMS wrongly said he owed arrears, leading to stress, depression, job loss, and financial hardship, and that CMS took too long to provide a breakdown.
University Hospitals Birmingham NHS Foundation Trust (P-005127)
NHS in England
Closed After Initial Enquiries
Access
Choice and Consent
Drugs / medication
Nursing care
AI summary: Miss A complained about restricted visits, catheterization without consent, lack of inhaler, and discharge with an unexplained wound, causing her mother distress.
A practice in the Walsall area (P-005117)
NHS in England
Closed After Initial Enquiries
Treatment
AI summary: Mr B complained the Practice failed to appropriately identify and treat his groin pain between June 2023 and July 2024, delaying access to specialist advice.
University Hospitals of North Midlands NHS Trust (P-005121)
NHS in England
Closed After Initial Enquiries
Treatment
Treatment
Treatment
Treatment
AI summary: Ms A complained about inadequate care for her daughter X, including inappropriate diet, over-medication, forced PEG feeding, TPN tube insertion, and failure to consider disabilities.
East and North Hertfordshire Teaching NHS Trust (P-005123)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Mr O complained his father received inadequate care, including lack of encouragement to eat, delayed nutritionist referral, falls with unwound wounds, changing diagnoses and a long discharge process.
Sheffield Teaching Hospitals NHS Foundation Trust (P-005120)
NHS in England
Partly Upheld
Diagnosis
Surgery
AI summary: Mrs B complained about delays in assessments and treatment for her mother, failures to recognise sepsis, incorrect catheter insertion, and incorrect anaesthetic dosage.
Driver and Vehicle Licensing Agency (P-005118)
UK Government
Closed After Initial Enquiries
Complaint handling
Complaint handling
AI summary: Mr D complained the DVLA did not adhere to a recommendation to award his daughter £400 for failings in the relicensing process, and the sum was insufficient.
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.