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Health / OmbudsmanUnited Kingdom
Free PHSO Complaint Template
A PHSO complaint is the United Kingdom statutory route for resolving complaints about NHS care, government departments and arm-length bodies after the local-resolution stage has been exhausted. The Parliamentary and Health Service Ombudsman investigates under the Health Service Commissioners Act 1993 (NHS side) and the Parliamentary Commissioner Act 1967 (parliamentary side). The complaint is brought within twelve months of awareness, with discretionary extension. PHSO applies a four-stage test for injustice — service failure or maladministration, injustice, causation and suitable remedy — and recommends remedies on a published severity scale from acknowledgment and apology through to substantial financial redress and structural change. Our free United Kingdom template builds a structured complaint statement covering complainant particulars, NHS body identification, event details, Stage 1 local resolution history and suitable remedy sought, with four Expert clauses on the PHSO four-stage test, Bradley starting-point doctrine, PHSO severity scale + structural change and twelve-month extension argument.
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Complaint to the Parliamentary and Health Service Ombudsman
Health Service Commissioners Act 1993 + PHSO Complaint Standards · 12 June 2026
Margaret Patricia Holloway
47 Lindale Avenue, Leeds LS17 6PR
0113 555 2284
mp.holloway@email.co.uk
12 June 2026
Parliamentary and Health Service Ombudsman
Citygate, Mosley Street, Manchester M2 3HQ
RE: Complaint against St Anselm Hospital NHS Foundation Trust — Dr Hannah Pemberton, Consultant Acute Physician (admitting clinician on 22 September 2025) and the wider on-call medical team
This complaint is made to the Parliamentary and Health Service Ombudsman under the Health Service Commissioners Act 1993 following the local-resolution response issued (or absence of response) by St Anselm Hospital NHS Foundation Trust under the NHS (Complaints) Regulations 2009 (SI 2009/309) and the PHSO Complaint Standards Framework. The complainant confirms that local resolution has been engaged and the complaint is brought within the twelve-month window or that the Ombudsman is invited to extend it on the grounds set out below. The complaint, the injustice suffered and the suitable remedy sought are particularised in the statement that follows.
This complaint is made to the Parliamentary and Health Service Ombudsman under the Health Service Commissioners Act 1993 following the local-resolution response issued (or absence of response) by St Anselm Hospital NHS Foundation Trust under the NHS (Complaints) Regulations 2009 (SI 2009/309) and the PHSO Complaint Standards Framework. The complainant confirms that local resolution has been engaged and the complaint is brought within the twelve-month window or that the Ombudsman is invited to extend it on the grounds set out below. The complaint, the injustice suffered and the suitable remedy sought are particularised in the statement that follows.
1. COMPLAINANT PARTICULARS
| NAME | Margaret Patricia Holloway |
| ADDRESS | 47 Lindale Avenue, Leeds LS17 6PR |
| TELEPHONE | 0113 555 2284 |
| mp.holloway@email.co.uk | |
| DATE OF BIRTH | 22 April 1957 |
| NHS NUMBER | 485 777 3217 |
| PATIENT (IF REPRESENTATIVE) | Albert Reginald Holloway (deceased) |
| RELATIONSHIP TO PATIENT | Daughter and personal representative under grant of probate dated 14 March 2026 |
2. NHS BODY COMPLAINED AGAINST
| NHS BODY NAME | St Anselm Hospital NHS Foundation Trust |
| NHS BODY TYPE | NHS acute hospital trust |
| NHS BODY ADDRESS | Patient Experience Team, St Anselm Hospital, Walbrook Road, Leeds LS9 7TR |
| HOSPITAL OR SITE | St Anselm Hospital — Acute Medical Unit, Ward 14 |
| CLINICIAN (NAME AND ROLE) | Dr Hannah Pemberton, Consultant Acute Physician (admitting clinician on 22 September 2025) and the wider on-call medical team |
3. EVENT DETAILS.
(a) Date of the event: 22 September 2025
(b) Location of the event: St Anselm Hospital, Acute Medical Unit, Ward 14
(c) Brief facts:
Mr Holloway was admitted on the evening of 22 September 2025 via the Emergency Department with reported acute confusion, falls and reduced oral intake over the preceding seventy-two hours. He was transferred to the Acute Medical Unit at 03:10 on 23 September 2025 without senior medical review. He was found unresponsive on the morning ward round and was confirmed deceased at 09:18. The internal clinical incident review identified failure to recognise sepsis on admission, absence of the documented National Early Warning Score (NEWS2) escalation between 03:10 and 08:40, and a missed dose of empirical broad-spectrum antibiotics that had been prescribed but not administered.
(a) Date of the event: 22 September 2025
(b) Location of the event: St Anselm Hospital, Acute Medical Unit, Ward 14
(c) Brief facts:
Mr Holloway was admitted on the evening of 22 September 2025 via the Emergency Department with reported acute confusion, falls and reduced oral intake over the preceding seventy-two hours. He was transferred to the Acute Medical Unit at 03:10 on 23 September 2025 without senior medical review. He was found unresponsive on the morning ward round and was confirmed deceased at 09:18. The internal clinical incident review identified failure to recognise sepsis on admission, absence of the documented National Early Warning Score (NEWS2) escalation between 03:10 and 08:40, and a missed dose of empirical broad-spectrum antibiotics that had been prescribed but not administered.
4. STAGE 1 LOCAL RESOLUTION HISTORY.
(a) Date Stage 1 complaint submitted to the NHS body: 8 November 2025
(b) Date final response received: 18 February 2026
(c) Stage 1 outcome: Complaint partially upheld at local resolution
(d) Summary of the Stage 1 final response:
The Trust Patient Experience Team final response acknowledged that the NEWS2 escalation was not documented between 03:10 and 08:40 on 23 September 2025 and that the prescribed dose of piperacillin-tazobactam at 04:00 had not been administered. The response concluded that prompt antibiotic administration would not on the balance of probabilities have altered the outcome and declined to offer apology for the missed NEWS2 escalation on the basis that the clinical incident review classified the failure as low harm. The complainant disputes the conclusion on causation and the no-apology decision.
The complainant confirms that local resolution under the NHS (Complaints) Regulations 2009 has been engaged and the response (or absence of response) leaves the matter unresolved. The complaint is referred to the Parliamentary and Health Service Ombudsman for independent investigation.
(a) Date Stage 1 complaint submitted to the NHS body: 8 November 2025
(b) Date final response received: 18 February 2026
(c) Stage 1 outcome: Complaint partially upheld at local resolution
(d) Summary of the Stage 1 final response:
The Trust Patient Experience Team final response acknowledged that the NEWS2 escalation was not documented between 03:10 and 08:40 on 23 September 2025 and that the prescribed dose of piperacillin-tazobactam at 04:00 had not been administered. The response concluded that prompt antibiotic administration would not on the balance of probabilities have altered the outcome and declined to offer apology for the missed NEWS2 escalation on the basis that the clinical incident review classified the failure as low harm. The complainant disputes the conclusion on causation and the no-apology decision.
The complainant confirms that local resolution under the NHS (Complaints) Regulations 2009 has been engaged and the response (or absence of response) leaves the matter unresolved. The complaint is referred to the Parliamentary and Health Service Ombudsman for independent investigation.
5. COMPLAINT SUMMARY AND INJUSTICE.
(a) Specific failures alleged:
(1) Failure to recognise sepsis on admission on 22 September 2025 despite presenting features of acute confusion, falls and tachycardia recorded in the Emergency Department triage notes; (2) failure to document NEWS2 escalation between 03:10 and 08:40 on 23 September 2025 in breach of the Trust own deteriorating-patient policy; (3) failure to administer the prescribed dose of empirical antibiotics at 04:00 in breach of the Sepsis Six bundle adopted by the Trust; (4) failure of the local-resolution response to apologise for the documented NEWS2 escalation failure on the basis that the clinical incident review classified the failure as low harm; (5) failure to take the matter forward to a structured incident review under the Patient Safety Incident Response Framework.
(b) Injustice suffered:
The family suffered avoidable distress through loss of an opportunity for timely sepsis recognition and antibiotic administration that would, on contemporaneous published evidence, have improved the chances of survival from severe sepsis. The complainant has been left without an apology for the documented NEWS2 escalation failure and without confidence that comparable failures will be addressed in future admissions. The financial loss includes funeral costs prematurely incurred, time taken off work to pursue the local complaint, and an independent expert opinion fee.
(a) Specific failures alleged:
(1) Failure to recognise sepsis on admission on 22 September 2025 despite presenting features of acute confusion, falls and tachycardia recorded in the Emergency Department triage notes; (2) failure to document NEWS2 escalation between 03:10 and 08:40 on 23 September 2025 in breach of the Trust own deteriorating-patient policy; (3) failure to administer the prescribed dose of empirical antibiotics at 04:00 in breach of the Sepsis Six bundle adopted by the Trust; (4) failure of the local-resolution response to apologise for the documented NEWS2 escalation failure on the basis that the clinical incident review classified the failure as low harm; (5) failure to take the matter forward to a structured incident review under the Patient Safety Incident Response Framework.
(b) Injustice suffered:
The family suffered avoidable distress through loss of an opportunity for timely sepsis recognition and antibiotic administration that would, on contemporaneous published evidence, have improved the chances of survival from severe sepsis. The complainant has been left without an apology for the documented NEWS2 escalation failure and without confidence that comparable failures will be addressed in future admissions. The financial loss includes funeral costs prematurely incurred, time taken off work to pursue the local complaint, and an independent expert opinion fee.
6. SUITABLE REMEDY SOUGHT.
The complainant invites the Parliamentary and Health Service Ombudsman to recommend the following remedies: (i) a written apology naming the failures and the personnel responsible; (j) a full explanation of what happened and why; (k) financial redress reflecting the injustice; (l) systemic action — training, policy revision or audit — to prevent recurrence.
Remedy narrative:
The complainant invites the Ombudsman to recommend (a) a written apology naming each of the failures above and the personnel responsible; (b) a full explanation of why the antibiotic dose was not administered and why the Sepsis Six bundle was not followed; (c) financial redress reflecting funeral costs, lost earnings and the independent expert fee; (d) structural action — a Trust-wide audit of NEWS2 escalation compliance, sepsis-pathway re-training for the Acute Medical Unit and review of the local-resolution policy that classified the failure as low harm.
The complainant invites the Ombudsman to recommend such further or other remedy as appears appropriate having regard to the PHSO published severity scale and the injustice suffered.
The complainant invites the Parliamentary and Health Service Ombudsman to recommend the following remedies: (i) a written apology naming the failures and the personnel responsible; (j) a full explanation of what happened and why; (k) financial redress reflecting the injustice; (l) systemic action — training, policy revision or audit — to prevent recurrence.
Remedy narrative:
The complainant invites the Ombudsman to recommend (a) a written apology naming each of the failures above and the personnel responsible; (b) a full explanation of why the antibiotic dose was not administered and why the Sepsis Six bundle was not followed; (c) financial redress reflecting funeral costs, lost earnings and the independent expert fee; (d) structural action — a Trust-wide audit of NEWS2 escalation compliance, sepsis-pathway re-training for the Acute Medical Unit and review of the local-resolution policy that classified the failure as low harm.
The complainant invites the Ombudsman to recommend such further or other remedy as appears appropriate having regard to the PHSO published severity scale and the injustice suffered.
7. PHSO FOUR-STAGE TEST FOR INJUSTICE.
PHSO evaluates complaints by reference to a four-stage analysis: (a) service failure or maladministration in the way the body acted or failed to act; (b) injustice suffered by the complainant; (c) a causal link between the failure and the injustice; (d) suitable remedy sought.
(a) Service failure analysis:
The service failures consist of (a) failure to recognise sepsis on admission contrary to the Trust adopted Sepsis Six bundle and NICE NG51 sepsis recognition guidance; (b) failure to document NEWS2 escalation contrary to the Trust deteriorating-patient policy in force on 22-23 September 2025; (c) failure to administer the prescribed empirical antibiotics within the published one-hour window. Each failure is documented by the Trust own internal clinical incident review.
(b) Maladministration analysis:
On the Doy scope of maladministration the failures comprise neglect (failure to recognise presenting sepsis features), inattention (failure to document the NEWS2 escalation), incompetence (failure to administer the prescribed antibiotics) and arbitrariness (the local-resolution conclusion that no apology was due on the basis of the low-harm classification). The cumulative pattern engages each head independently and supports a finding of maladministration on the Doy scope.
(c) Injustice and causation:
The injustice consists of the avoidable loss of the chance of timely sepsis treatment that, on the contemporaneous published evidence collated by the complainant independent expert (Professor Aisha Gardner, Consultant in Intensive Care Medicine at the Royal Northern Infirmary), would on the balance of probabilities have improved the chances of survival. The causal link from the failures to the injustice is established by the timeline — failure at 03:10 leading directly to absence of intervention until 08:40 and confirmed death at 09:18.
(d) Evidential position:
The evidential record consists of the Emergency Department triage notes, the Acute Medical Unit observation chart between 03:10 and 09:18, the prescription record showing the prescribed and not-administered dose, the Trust internal clinical incident review report dated 30 October 2025, the independent expert opinion of Professor Gardner dated 12 December 2025 and the family witness statement of Mrs Margaret Holloway dated 28 October 2025.
PHSO evaluates complaints by reference to a four-stage analysis: (a) service failure or maladministration in the way the body acted or failed to act; (b) injustice suffered by the complainant; (c) a causal link between the failure and the injustice; (d) suitable remedy sought.
(a) Service failure analysis:
The service failures consist of (a) failure to recognise sepsis on admission contrary to the Trust adopted Sepsis Six bundle and NICE NG51 sepsis recognition guidance; (b) failure to document NEWS2 escalation contrary to the Trust deteriorating-patient policy in force on 22-23 September 2025; (c) failure to administer the prescribed empirical antibiotics within the published one-hour window. Each failure is documented by the Trust own internal clinical incident review.
(b) Maladministration analysis:
On the Doy scope of maladministration the failures comprise neglect (failure to recognise presenting sepsis features), inattention (failure to document the NEWS2 escalation), incompetence (failure to administer the prescribed antibiotics) and arbitrariness (the local-resolution conclusion that no apology was due on the basis of the low-harm classification). The cumulative pattern engages each head independently and supports a finding of maladministration on the Doy scope.
(c) Injustice and causation:
The injustice consists of the avoidable loss of the chance of timely sepsis treatment that, on the contemporaneous published evidence collated by the complainant independent expert (Professor Aisha Gardner, Consultant in Intensive Care Medicine at the Royal Northern Infirmary), would on the balance of probabilities have improved the chances of survival. The causal link from the failures to the injustice is established by the timeline — failure at 03:10 leading directly to absence of intervention until 08:40 and confirmed death at 09:18.
(d) Evidential position:
The evidential record consists of the Emergency Department triage notes, the Acute Medical Unit observation chart between 03:10 and 09:18, the prescription record showing the prescribed and not-administered dose, the Trust internal clinical incident review report dated 30 October 2025, the independent expert opinion of Professor Gardner dated 12 December 2025 and the family witness statement of Mrs Margaret Holloway dated 28 October 2025.
8. BRADLEY STARTING-POINT POSITION.
R (Bradley) v Secretary of State for Work and Pensions [2008] EWCA Civ 36 established that an Ombudsman finding is the starting point for the recipient public authority response and may be departed from only on a rational basis. R (Equitable Members Action Group) v HM Treasury [2009] EWHC 2495 (Admin) applied the same approach to the government response to a published PHSO report.
(a) Recipient authority response expectation:
The Trust is expected to treat any PHSO finding as the starting point of its response per <em>R (Bradley) v Secretary of State for Work and Pensions</em> [2008] EWCA Civ 36 and to depart from it only on a rational basis founded in fresh evidence not previously before the Ombudsman. The Trust is not at liberty simply to disagree with the merits of the finding or to repeat the local-resolution conclusion that classified the failure as low harm.
(b) Rational departure test:
Any departure from a PHSO finding by the Trust must be supported by (a) fresh evidence not previously before the Ombudsman; (b) a reasoned departure document published to the complainant; and (c) a written confirmation that the Trust has considered the Cabinet Office published guidance on responding to Ombudsman findings. Bald disagreement with the merits or restatement of the local-resolution conclusion will not satisfy the Bradley test.
(c) Cabinet Office and NHS guidance position:
Cabinet Office published guidance on responding to Ombudsman findings, NHS England published policies on patient safety incident responses, and the Civil Service Code provisions on standards in public life reinforce the Bradley starting point. The Trust should publish its reflective response on the failures identified and demonstrate its compliance with the structural change recommended.
R (Bradley) v Secretary of State for Work and Pensions [2008] EWCA Civ 36 established that an Ombudsman finding is the starting point for the recipient public authority response and may be departed from only on a rational basis. R (Equitable Members Action Group) v HM Treasury [2009] EWHC 2495 (Admin) applied the same approach to the government response to a published PHSO report.
(a) Recipient authority response expectation:
The Trust is expected to treat any PHSO finding as the starting point of its response per <em>R (Bradley) v Secretary of State for Work and Pensions</em> [2008] EWCA Civ 36 and to depart from it only on a rational basis founded in fresh evidence not previously before the Ombudsman. The Trust is not at liberty simply to disagree with the merits of the finding or to repeat the local-resolution conclusion that classified the failure as low harm.
(b) Rational departure test:
Any departure from a PHSO finding by the Trust must be supported by (a) fresh evidence not previously before the Ombudsman; (b) a reasoned departure document published to the complainant; and (c) a written confirmation that the Trust has considered the Cabinet Office published guidance on responding to Ombudsman findings. Bald disagreement with the merits or restatement of the local-resolution conclusion will not satisfy the Bradley test.
(c) Cabinet Office and NHS guidance position:
Cabinet Office published guidance on responding to Ombudsman findings, NHS England published policies on patient safety incident responses, and the Civil Service Code provisions on standards in public life reinforce the Bradley starting point. The Trust should publish its reflective response on the failures identified and demonstrate its compliance with the structural change recommended.
9. PHSO SEVERITY SCALE AND STRUCTURAL CHANGE.
PHSO recommends remedies on a published severity scale ranging from acknowledgment and apology, through service improvement, to substantial financial redress for severe injustice. Structural change — staff training, policy revision and audit arrangements — is recommended alongside individual restoration where the failure is systemic.
(a) Severity band sought: High — apology, structural change with audit and a substantial consolatory payment for sustained injustice
(b) Structural change sought:
The complainant invites the Ombudsman to recommend (a) a Trust-wide audit of NEWS2 escalation compliance covering at least the preceding twelve months across the Acute Medical Unit and the Emergency Department; (b) re-training of the on-call medical and nursing teams in the Sepsis Six bundle and NEWS2 escalation; (c) revision of the local-resolution policy to remove the low-harm classification basis for declining apology; and (d) publication of an audit report to the complainant within six months.
(c) Financial redress position:
The complainant invites the Ombudsman to recommend financial redress reflecting (a) funeral costs incurred prematurely on 1 October 2025 (receipted at GBP 4,820); (b) loss of earnings for the complainant occasioned by pursuing the local-resolution complaint and the PHSO referral (calculated at GBP 1,640); (c) the independent expert opinion fee of Professor Gardner (receipted at GBP 1,250); and (d) a consolatory payment reflecting the distress occasioned by the local-resolution conclusion and the absence of apology.
(d) Comparable case position:
Comparable published PHSO determinations in the high-severity band include sepsis-recognition failures, NEWS2 escalation failures and missed antibiotic doses where the published outcome included apology, structural audit and a consolatory payment in the range of GBP 1,000 to GBP 5,000. The complainant invites the Ombudsman to place this case at the upper end of the band reflecting the cumulative pattern and the absence of apology at local resolution.
PHSO recommends remedies on a published severity scale ranging from acknowledgment and apology, through service improvement, to substantial financial redress for severe injustice. Structural change — staff training, policy revision and audit arrangements — is recommended alongside individual restoration where the failure is systemic.
(a) Severity band sought: High — apology, structural change with audit and a substantial consolatory payment for sustained injustice
(b) Structural change sought:
The complainant invites the Ombudsman to recommend (a) a Trust-wide audit of NEWS2 escalation compliance covering at least the preceding twelve months across the Acute Medical Unit and the Emergency Department; (b) re-training of the on-call medical and nursing teams in the Sepsis Six bundle and NEWS2 escalation; (c) revision of the local-resolution policy to remove the low-harm classification basis for declining apology; and (d) publication of an audit report to the complainant within six months.
(c) Financial redress position:
The complainant invites the Ombudsman to recommend financial redress reflecting (a) funeral costs incurred prematurely on 1 October 2025 (receipted at GBP 4,820); (b) loss of earnings for the complainant occasioned by pursuing the local-resolution complaint and the PHSO referral (calculated at GBP 1,640); (c) the independent expert opinion fee of Professor Gardner (receipted at GBP 1,250); and (d) a consolatory payment reflecting the distress occasioned by the local-resolution conclusion and the absence of apology.
(d) Comparable case position:
Comparable published PHSO determinations in the high-severity band include sepsis-recognition failures, NEWS2 escalation failures and missed antibiotic doses where the published outcome included apology, structural audit and a consolatory payment in the range of GBP 1,000 to GBP 5,000. The complainant invites the Ombudsman to place this case at the upper end of the band reflecting the cumulative pattern and the absence of apology at local resolution.
10. TIME-LIMIT POSITION AND EXTENSION ARGUMENT.
Complaints to PHSO must normally be brought within twelve months of the matter coming to the complainant attention. The Ombudsman has a published discretion to extend the window in suitable cases.
(a) Awareness date argument:
The complainant first became fully aware of the underlying failures on receipt of the Trust internal clinical incident review report on 30 October 2025. The complaint to PHSO is filed on 12 June 2026 which is comfortably within the twelve months running from the awareness date. The complainant relies on the awareness date for the time-limit calculation rather than the date of death.
(b) Continuing failure position:
In any event the local-resolution conclusion of 18 February 2026 that no apology is due on the basis of the low-harm classification is itself a continuing failure that brings the complaint within the twelve-month window measured from that response date. The continuing failure analysis is independent of the awareness-date analysis and provides an alternative basis for the time-limit position.
(c) Exceptional circumstances supporting extension:
No exceptional circumstances are relied on to extend the window — the complaint is comfortably within time on either the awareness-date or the continuing-failure analysis. The complainant nonetheless invites the Ombudsman to confirm the favourable time-limit position at the outset of the investigation so that the substantive analysis can proceed without preliminary objection.
Complaints to PHSO must normally be brought within twelve months of the matter coming to the complainant attention. The Ombudsman has a published discretion to extend the window in suitable cases.
(a) Awareness date argument:
The complainant first became fully aware of the underlying failures on receipt of the Trust internal clinical incident review report on 30 October 2025. The complaint to PHSO is filed on 12 June 2026 which is comfortably within the twelve months running from the awareness date. The complainant relies on the awareness date for the time-limit calculation rather than the date of death.
(b) Continuing failure position:
In any event the local-resolution conclusion of 18 February 2026 that no apology is due on the basis of the low-harm classification is itself a continuing failure that brings the complaint within the twelve-month window measured from that response date. The continuing failure analysis is independent of the awareness-date analysis and provides an alternative basis for the time-limit position.
(c) Exceptional circumstances supporting extension:
No exceptional circumstances are relied on to extend the window — the complaint is comfortably within time on either the awareness-date or the continuing-failure analysis. The complainant nonetheless invites the Ombudsman to confirm the favourable time-limit position at the outset of the investigation so that the substantive analysis can proceed without preliminary objection.
11. DOCUMENTS ENCLOSED. The complainant encloses with this statement:
(a) Stage 1 complaint correspondence and the local body final response;
(b) Relevant clinical records, hospital discharge summaries and GP correspondence;
(c) Independent expert opinion or second-opinion correspondence where obtained;
(d) Witness statements from family, friends and other patients where relevant;
(e) Evidence of injustice — out-of-pocket receipts, loss-of-earnings calculations, medical evidence of deterioration;
(f) Consent forms for PHSO to access the underlying clinical record where required.
(a) Stage 1 complaint correspondence and the local body final response;
(b) Relevant clinical records, hospital discharge summaries and GP correspondence;
(c) Independent expert opinion or second-opinion correspondence where obtained;
(d) Witness statements from family, friends and other patients where relevant;
(e) Evidence of injustice — out-of-pocket receipts, loss-of-earnings calculations, medical evidence of deterioration;
(f) Consent forms for PHSO to access the underlying clinical record where required.
12. DECLARATION AND CONSENT. The complainant confirms that the particulars set out in this statement and the supporting documents are true and correct to the best of the complainant knowledge and belief. The complainant consents to the Parliamentary and Health Service Ombudsman accessing the underlying clinical, administrative and complaint-handling records held by the NHS body and any related arm-length body for the purposes of investigating this complaint.
COMPLAINANT
Margaret Patricia Holloway
Date: ____________________
Available as a print-ready PDF or an editable Microsoft Word (.docx) file.
What Is a PHSO Complaint?
The Parliamentary and Health Service Ombudsman (PHSO) is the United Kingdom statutory body for investigating complaints about NHS services in England and complaints about UK government departments and agencies. PHSO operates under the Health Service Commissioners Act 1993 (NHS side) and the Parliamentary Commissioner Act 1967 (parliamentary side). It is independent of the NHS, the Department of Health and Social Care, the UK Government and the Information Commissioner. Determinations are published (anonymised) and recommend remedies on a published severity scale.
A PHSO complaint is brought after the NHS local-resolution stage has been completed under the NHS (Complaints) Regulations 2009 (SI 2009/309) and the PHSO Complaint Standards Framework — local body acknowledgment within three working days, proportionate investigation and final response with reasons. Where the local body has not responded within the published timetable, the absence of response itself founds the PHSO referral. The parliamentary side traditionally requires MP referral; the NHS side has been direct since the 2013 reforms — a complainant may approach PHSO directly without MP introduction. The twelve-month time limit runs from the complainant becoming aware of the matter, with discretionary extension for late knowledge, continuing failure or exceptional circumstances.
PHSO evaluates complaints by reference to a four-stage analysis — (a) service failure or maladministration in the way the body acted or failed to act; (b) injustice suffered by the complainant; (c) a causal link between the failure and the injustice; (d) suitable remedy sought. The maladministration scope follows the long-standing test from R (Doy) v Commissioner for Local Administration [2001] EWCA Civ — bias, neglect, inattention, delay, incompetence, perversity, turpitude and arbitrariness. Per R (Bradley) v Secretary of State for Work and Pensions [2008] EWCA Civ 36, an Ombudsman finding is the starting point for the recipient public authority response and may be departed from only on a rational basis. Remedies are recommended on a published severity scale ranging from acknowledgment and apology through service improvement to substantial financial redress for severe injustice, with structural change — training, policy revision and audit — alongside individual restoration.
What's Covered in This Template
Our United Kingdom PHSO complaint template builds a structured complaint statement covering complainant particulars, NHS body identification, event details, Stage 1 local resolution history and suitable remedy sought, with four Expert clauses on the PHSO four-stage test, Bradley starting-point doctrine, PHSO severity scale and structural change, and twelve-month extension argument.
Complainant Particulars
Captures complainant identification — name, address, contact, date of birth, NHS number — and the basis for the complaint (self or representative). Representative complaints are common in PHSO practice — bereaved family member, advocate or solicitor — and the representative basis is documented at the outset with the relevant grant of probate or letters of administration where applicable.
NHS Body and Clinician Identification
Captures the NHS body — acute trust, mental health trust, GP practice, Integrated Care Board (ICB), community trust, ambulance trust, dental practice, community pharmacy or other arm-length body. The post-July 2022 ICB framework following the Health and Care Act 2022 is captured directly. Where a specific clinician is named, the clinician name and role are recorded for the case-handler reference.
Event Details with Date and Brief Facts
Records the date of the event, the location and the brief facts. The brief facts are scoped to give the PHSO case-handler an immediate orientation; detailed clinical analysis goes into the failures and injustice sections. The format follows PHSO published intake guidance.
Stage 1 Local Resolution History
Captures the local complaint date, final response date and outcome (rejected in full, partially upheld, no response, other). The Stage 1 final response is quoted or summarised so the PHSO case-handler can compare it against the failures alleged in the complaint summary.
Failures Alleged and Injustice Suffered
Pre-frames the structured complaint summary — specific failures alleged in numbered form by reference to the NHS body own published policies, NICE guidance and applicable clinical bundles (Sepsis Six, NEWS2, Resuscitation Council UK), and the injustice suffered (distress, financial loss, lost opportunity, deterioration in clinical condition, lost chance of survival).
Suitable Remedy Sought
Pre-stages the remedy sought — written apology naming failures and personnel, full explanation, financial redress, systemic action (training, policy revision, audit). PHSO recommends remedies on a published severity scale; pre-framing the remedy anchors the eventual recommendation.
PHSO Four-Stage Test — Service Failure + Maladministration + Injustice + Causation (Expert)
Expert clause structures the PHSO four-stage analysis — service failure or maladministration in the body conduct; injustice suffered by the complainant; causal link from the failure to the injustice; suitable remedy. The maladministration scope follows R (Doy) — bias, neglect, inattention, delay, incompetence, perversity, turpitude and arbitrariness.
Bradley Starting-Point Doctrine (Expert)
Expert clause pre-stages the recipient public authority duty to treat the Ombudsman finding as the starting point of its response per R (Bradley) v Secretary of State for Work and Pensions [2008] EWCA Civ 36 and the parallel R (Equitable Members Action Group) v HM Treasury [2009] EWHC 2495 (Admin) authority. Departure is permitted only on a rational basis founded in fresh evidence.
PHSO Severity Scale and Structural Change (Expert)
Expert clause pre-frames the band on the published PHSO severity scale — low (apology + service-improvement), medium (apology + named systemic action + modest consolatory payment), high (apology + structural change with audit + substantial consolatory payment), severe (apology + substantial financial redress + structural change + published reflective response). Comparable published PHSO determinations are cited to anchor the band.
Twelve-Month Time Limit and Extension Argument (Expert)
Expert clause structures the time-limit position — awareness date analysis (when the complainant first became aware), continuing failure analysis (where the matter is a continuing course of conduct), and exceptional circumstances supporting Ombudsman discretion to extend (serious illness, bereavement, professional adviser failure, late disclosure by the NHS body).
Documents Enclosed Index
Pre-drafts the documents enclosed index — Stage 1 correspondence and final response, clinical records and discharge summaries, independent expert opinion or second-opinion correspondence, witness statements, evidence of injustice (receipts, loss of earnings, medical evidence of deterioration) and consent forms for PHSO access to the underlying clinical record.
Declaration and Consent
Pre-staged declaration confirming the truth of the particulars and consenting to PHSO access to the underlying clinical, administrative and complaint-handling records held by the NHS body and any related arm-length body for the purposes of investigation.
How to Build a PHSO Complaint
Follow these steps to produce a structured United Kingdom PHSO complaint statement that lands the four-stage test analysis and engages the Bradley starting-point doctrine.
- 1
Confirm Stage 1 Local Resolution Is Complete
PHSO normally requires the NHS body local-resolution stage to be completed before the complaint is referred. Record the date the local complaint was submitted, the date the final response was received and the outcome. Where the local body has not responded within the published timetable, the absence of response itself founds the PHSO referral.
- 2
Capture Complainant Details and Basis
Record the complainant full name, address, contact details, date of birth and NHS number. Where the complaint is brought on behalf of someone else, record the patient name and the representative basis — grant of probate, letters of administration, parental responsibility, advocate appointment.
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Identify the NHS Body and Clinician
Capture the NHS body name, type and address. For specific clinical complaints, capture the named clinician and role. The post-July 2022 framework captures Integrated Care Boards (replacing the abolished Clinical Commissioning Groups under the Health and Care Act 2022) as a recognised body type.
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Record the Event Details
Record the date of the event, the location and the brief facts. Brief facts go on the front page of the statement for case-handler orientation; detailed clinical analysis appears in the failures alleged and injustice suffered sections that follow.
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Quote the Stage 1 Final Response
Quote or summarise the local body Stage 1 final response — what was acknowledged, what was disputed and the basis for any departure from the complainant position. The PHSO case-handler compares the response against the failures alleged in the complaint summary.
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Set Out the Failures Alleged
Set out the specific failures alleged in numbered form by reference to the NHS body own published policies, NICE guidance and applicable clinical bundles. The numbered list is the structural backbone of the statement — each failure should map to one or more heads of maladministration on the Doy scope (bias, neglect, inattention, delay, incompetence, perversity, turpitude, arbitrariness).
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Identify the Injustice Suffered
Identify the injustice — distress, financial loss, lost opportunity, deterioration in clinical condition, lost chance of survival — and the causal link from the failures to the injustice. The injustice analysis must show how the failures directly led to the consequences pleaded.
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State the Suitable Remedy Sought
State the remedies sought — apology naming failures and personnel, full explanation, financial redress, systemic action (training, policy revision, audit). Pre-frame the band on the PHSO severity scale — low / medium / high / severe — and cite comparable published determinations to anchor the band.
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Structure the Four-Stage Test (Expert)
Expert clause. Structure the PHSO four-stage analysis — service failure or maladministration, injustice, causation, remedy. Each limb is addressed in turn with documented evidence — contemporaneous clinical records, NICE guidance citations, independent expert opinion, witness statements.
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Engage Bradley Starting-Point Doctrine (Expert)
Expert clause. Pre-stage the recipient public authority duty under R (Bradley) v Secretary of State for Work and Pensions [2008] EWCA Civ 36 to treat the Ombudsman finding as the starting point of its response. Departure is permitted only on a rational basis founded in fresh evidence — bald disagreement with the merits or restatement of the local-resolution conclusion will not satisfy the Bradley test.
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Frame the Severity Band on the Published Scale (Expert)
Expert clause. Frame the band sought on the published PHSO severity scale and identify the structural change sought (audit, training, policy revision, published reflective response). Cite comparable published PHSO determinations to anchor the band and the financial redress position.
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Pre-Stage the Time-Limit Position (Expert)
Expert clause. Pre-stage the time-limit position — awareness date analysis, continuing failure analysis, exceptional circumstances supporting Ombudsman discretion to extend. The complaint should not be derailed by a preliminary time-limit objection at intake.
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Legal Considerations — PHSO Complaint
The Parliamentary and Health Service Ombudsman is established under the Health Service Commissioners Act 1993 (NHS side) and the Parliamentary Commissioner Act 1967 (parliamentary side). PHSO investigates complaints about NHS services in England, UK government departments and arm-length bodies. The Local Government and Social Care Ombudsman (LGSCO) is a separate body covering adult social care and council services in England.
This template is for general information and does not constitute legal advice. PHSO complaints involve substantive public law, healthcare regulation, NICE guidance, the Bradley starting-point doctrine and detailed clinical evidence. Where the complaint is complex, involves serious financial loss, engages the Equality Act 2010 or rests on contested clinical fact, advice from a solicitor experienced in clinical negligence or public law, an independent expert clinician and (where appropriate) the Patient Advice and Liaison Service (PALS) is recommended. The Citizens Advice service provides free first-tier guidance; PHSO publishes detailed intake guidance and a Determinations and Annual Report archive at ombudsman.org.uk.
Reviewed for the United Kingdom (England and Wales primarily — Scotland and Northern Ireland have separate ombudsmen)
Statutory Basis and Scope
PHSO operates under two statutes — the Health Service Commissioners Act 1993 (NHS side) and the Parliamentary Commissioner Act 1967 (parliamentary side). The NHS side covers complaints about NHS services in England — acute trusts, mental health trusts, GP practices, Integrated Care Boards (ICBs), community trusts, ambulance trusts, dental practices and community pharmacies. The parliamentary side covers UK Government departments, agencies and certain arm-length bodies. Adult social care and council services in England fall under the Local Government and Social Care Ombudsman, a separate body. Scotland has the Scottish Public Services Ombudsman; Wales has the Public Services Ombudsman for Wales; Northern Ireland has the Northern Ireland Public Services Ombudsman.
Local Resolution Prerequisite — NHS (Complaints) Regulations 2009
Before PHSO, the complainant must normally complete the NHS local-resolution stage under the NHS (Complaints) Regulations 2009 (SI 2009/309). The local body must acknowledge within three working days, investigate proportionately and issue a final response with reasons. The PHSO Complaint Standards Framework, published progressively from 2022, sets the practice standard NHS bodies are expected to follow alongside the 2009 Regulations. Where the local body has not responded within the published timetable, the absence of response founds the PHSO referral.
Four-Stage Test and the Doy Scope
PHSO evaluates complaints by reference to a four-stage analysis — service failure or maladministration; injustice; causation; remedy. The maladministration scope follows R (Doy) v Commissioner for Local Administration [2001] EWCA Civ — bias, neglect, inattention, delay, incompetence, perversity, turpitude and arbitrariness. The pattern of failures is often more decisive than any single failure — cumulative failures that fall under multiple heads of the Doy scope support a finding of systemic maladministration warranting structural change.
Bradley Starting-Point Doctrine
Per R (Bradley) v Secretary of State for Work and Pensions [2008] EWCA Civ 36, an Ombudsman finding is the starting point for the recipient public authority response and may be departed from only on a rational basis. Per R (Equitable Members Action Group) v HM Treasury [2009] EWHC 2495 (Admin), the same approach applies to the UK Government response to a published PHSO report. Bald disagreement with the merits or restatement of the local-resolution conclusion will not satisfy the Bradley test — departure requires fresh evidence and a reasoned departure document. Cabinet Office guidance on responding to Ombudsman findings reinforces the starting-point principle.
Severity Scale and Remedies
PHSO recommends remedies on a published severity scale from low (acknowledgment and apology with short service-improvement action) through medium (apology with named systemic action and modest consolatory payment) and high (apology with structural change, audit and substantial consolatory payment for sustained injustice) to severe (apology with substantial financial redress, structural change and published reflective response). Comparable published PHSO determinations and annual report case studies provide the benchmark for the band sought.
Twelve-Month Time Limit and Extension
Complaints to PHSO must normally be brought within twelve months of the matter coming to the complainant attention. The Ombudsman has a published discretion to extend the window in suitable cases — late knowledge of the failure (typically following receipt of a clinical incident review report or independent expert opinion), continuing course of conduct (where the matter is itself a continuing failure), professional adviser failure to act (where the complainant relied on solicitor or advocate who failed to advise), or exceptional circumstances (serious illness, bereavement, late disclosure by the NHS body).
Frequently Asked Questions
Build Your PHSO Complaint
Produce a structured United Kingdom PHSO complaint statement under the Health Service Commissioners Act 1993 — complainant particulars (self or representative basis), NHS body and clinician identification (acute trust, mental health trust, GP practice, Integrated Care Board, community trust, ambulance trust, dental, pharmacy or other arm-length body), event details with date and brief facts, Stage 1 local resolution history with final response summary, failures alleged in numbered form and injustice suffered, suitable remedy sought (apology, explanation, financial redress, systemic action), and four Expert clauses on the PHSO four-stage test (service failure + maladministration + injustice + causation), Bradley starting-point doctrine (R (Bradley) v Secretary of State for Work and Pensions [2008] EWCA Civ 36 with R (Equitable Members) v HM Treasury [2009] EWHC 2495 (Admin) reinforcement), PHSO severity scale and structural change (low / medium / high / severe band selection with comparable published determinations) and twelve-month extension argument (awareness date, continuing failure, exceptional circumstances). Sent to Citygate, Mosley Street, Manchester M2 3HQ.
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