Final investigation report of a complaint about UK Visas and Immigration
Our investigation found failings at UK Visas and Immigration (UKVI) in this case of a Windrush claimant who waited over a year before getting a response.
Source · Ombudsmen & enforcement
PHSO Systemic Investigations
4,426 casework decisions
82 systemic investigations
22 recommendations
updated to 17 Aug 2026
Published systemic investigation reports from the Parliamentary and Health Service Ombudsman. Browse recommendations, the responses recorded and follow-up evidence. Individual casework decisions are available in a separate register.
Systemic investigation reports
A complaint about the Ministry of Justice's failure to properly communicate with a member of the public
The Ministry of Justice failed to properly communicate with a member of the public about a potential local independent inquiry into the disposal of ashes following the death of their baby and others.
Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments (Executive Summary)
Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments
This report follows an invitation from the House of Commons Select Committee on Public Administration and Constitutional Affairs to explore the state of local complaints handling across the NHS and UK Government departments.
Survey of experiences of NHS mental health care in England
Our survey asked people about their experiences of using NHS mental health services in England. The survey results show that people continue to experience the five common failings we identified in our Maintaining Momentum report.
Report of a review into PHSO’s handling of Mr Nic Hart’s case from August 2014 to December 2017
This report sets out the findings of our review into the way we handled Mr Nic Hart’s complaint about the NHS care and treatment of his daughter, and subsequent investigation.
Complaints about the NHS in England: Quarter 1 2019-20
This report presents statistics on complaints about the NHS in England (Quarter 1 2019-20).
Complaints about the NHS in England Quarter 4 2018-19
This report presents statistics on complaints about the NHS in England (Quarter 4 2018-19).
Second PHSO investigation into the Care Quality Commission’s regulation of the Fit and Proper Persons Requirement
This is the report of our second investigation into the Care Quality Commission’s (CQC) regulation of the Fit and Proper Persons Requirement (FPPR).
Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust
Complaints about the NHS in England Quarter 3 2018-19
This report presents statistics on complaints about the NHS in England (Quarter 3 2018-19).
The roles of the Parliamentary and Health Service Ombudsman and NHS Resolution: Information for NHS trusts
This document is for NHS trusts in England, particularly those staff who manage complaints and/or compensation claims raised against their trust.
Blowing the whistle: an investigation into the Care Quality Commission’s regulation of the Fit and Proper Persons Requirement
Complaints about UK government departments and agencies 2017-18
In 2017-18, we handled 6,606 complaints from the public about government departments, their agencies and other UK public organisations.
Complaints about the NHS in England: Quarter 2 2018-19
This report presents statistics on complaints about the NHS in England from July to September 2018 (Quarter 2 – 2018-19).
Complaints about the NHS in England: Quarter 1 2018-19
This report presents statistics on complaints about the NHS in England from April to June 2018 (Quarter 1).
Maintaining momentum: driving improvements in mental health care
This report highlights failings in NHS mental healthcare services, and the devastating human impact on patients and their families. The findings provide fresh impetus to deliver on the Five Year Forward View.
Ignoring the alarms: How NHS eating disorder services are failing patients
Systemic investigation into NHS eating disorder services, finding patients failed by inadequate training, poor transition from child to adult services, lack of coordination and insufficient specialist provision. PACAC follow-up (2019) found 'not enough action' taken. PHSO wrote to ministers again in March 2024 calling for …
Complaints about UK government departments and agencies, and some UK public organisations 2016-17
A report of investigations into complaints about Access to Work
Complaints about UK government departments and agencies, and some UK public organisations 2015-16
This report provides a summary of the key statistics we have collected about the complaints we have handled, and the investigations we undertook in 2015-16 that involved UK government departments, agencies and some other UK public organisations.
Driven to despair
Our investigation into how drivers have been let down by the Driver and Vehicle Licensing Agency
Learning from mistakes
An investigation report into how the NHS failed to properly investigate the death of a three-year old child.
A report of investigations into unsafe discharge from hospital
This report focuses on nine experiences drawn from recent complaints we have investigated, which best illustrate the problems we are seeing with regards to unsafe discharge from hospital.
An opportunity to improve
We want to use our own experience of investigating complaints about GP practices to help the NHS support general practice to do better.
Latest casework decisions
A practice in the Dover area · P-005982
Mr X complains the Practice were poor at record keeping and failed to pass on information about his father's lack of mental capacity to the …
A dental practice in the Manchester area · P-005981
Mr A complains about a lack of dental interventions over several years. He also complains the Practice did not offer appropriate referrals and removed him …
An independent provider in the Wakefield area · P-005983
Mr D complains that the provider reduced his medication without communicating this with him.
HM Courts and Tribunals Service · P-005979
Mr C complains HMCTS will not cancel a County Court Judgement (CCJ) registered to his old address.
Guy's and St Thomas' NHS Foundation Trust · P-005980
Mr E complains about the care and treatment his son, received from the Trust between July and August 2023. Mr E complains the Trust discharged …
Bodies most often named
| # | Body | Investigations |
|---|---|---|
| 1 | Department for Work and Pensions | 4 |
| 2 | HM Government | 3 |
| 3 | Department of Health and Social Care / NHS England | 3 |
| 4 | Department of Health and Social Care | 2 |
| 5 | NHS England | 2 |
Section 10(3) reports
1 Section 10(3) report — these rare reports are laid before Parliament when organisations refuse to comply with PHSO recommendations.
What we do with each report
1
Ingest
Published PDF reports downloaded from ombudsman.org.uk. Full text extracted and stored.
2
Match
Body name in the report matched to canonical body registry using alias resolution and fuzzy matching.
3
Theme
Recommendation text classified against clinical and administrative themes using AI classification with human spot-checks.
4
Outcome
Acceptance status, compliance status and follow-up recommendations extracted and stored against the body record.