University Hospitals Birmingham NHS Foundation Trust

6. Mrs Y complains about aspects of the care and treatment of her partner by the Trust. Mrs Y specifically complains that the Trust:

• altered her partner’s medical records to make it appear as if illnesses were present after her partner left hospital and were not present when her partner was at the hospital.

• provided discharge letters with missing information • wrongly left her partner on co-careldopa for longer than needed • placed her partner on legal safeguarding for patients, who do not have capacity, so they could give him medication without having to discuss it with herself • did not provide a follow up appointment after her partner was discharged in August 2023 • failed to provide care to treat encephalitis.

7. Mrs Y says that because of these failings:

• her partner does not get treatment for anything, except for diabetes • her partner has been put in danger when needing medical care due to their incomplete/false medical record • her partner has been left bed bound and receives little help, meaning that Mrs Y has taken on a lot of the care and she has been unable to leave the house for long periods of time.

8. Mrs Y is seeking an investigation into how her partner’s medical records were altered and who had altered them. She is also seeking a review to be done into her partner’s case and a correct diagnosis to be made.

9. This is a summary of events to put the complaint in context. We have not included all the details as those involved are already aware of this information.

10. In 2021, Mrs Y’s partner was admitted to hospital, where it was confirmed, they had fluid and a bleed on the brain.

11. Mrs Y’s partner was discharged to a different hospital to have a stent fitted.

12. Mrs Y’s partner was unable to return home and so was discharged to a rehabilitation centre.

13. In the following month, Mrs Y’s partner was prescribed co-careldopla.

14. In late 2021, Mrs Y’s partner developed an infection and was admitted back to hospital. They were prescribed antibiotics and discharged.

15. In early 2022, Mrs Y’s partner was admitted to another hospital with pneumonia and was prescribed antibiotics.

16. Mrs Y’ partner was then discharged to a rehabilitation centre. They were then later discharged back home following an assessment.

17. Mrs Y’s partner was visited by a physiotherapist for five sessions.

18. In mid-2022, an urgent referral was made by their surgery. This was rejected though by the hospital due to the surgery supplying insufficient information.

19. In late 2022, Mrs Y’s partner was admitted to a hospital, where they were told they had a high white blood cell count. Mrs Y’s partner was showing signs of improvement and was going to be prescribed steroids.

20. At the end of 2022, Mrs Y’s partner started to deteriorate and needed to be catheterised.

21. At the start of 2023, Mrs Y’s partner was prescribed antivirals and antibiotics for encephalitis.

22. Mrs Y’s partner was discharged from the hospital to a care home in August 2023.

23. In early October 2023, Mrs Y’s partner was discharged back home.

24. Mrs Y stated in the complaint form that the problem started on 27 September 2023 when she received her partner’s medical record from the Trust.

25. Mrs Y contacted a solicitor, who told her that they would not be able to help until the medical records are corrected.

26. Mrs Y complained to the Trust when she became aware of the problem on 24 November 2024.

27. The Trust initially responded to Mrs Y’s complaint on 14 February 2025.

28. Mrs Y sends several emails responding to the Trust from 2 March 2025 to 23 May 2025.

29. The Trust sends their final response on 24 August 2025 to Mrs Y.

30. Mrs Y brings her complaint to the PHSO on 8 November 2025.

33. The NHS follows a records management code of practice called the NHS High-Quality Patient Records. Within this guidance it states records made by the NHS must be kept accurately.

34. This is underpinned by legal requirements to adhere to the GDPR and the Data Protection Act of 2018.

35. Contained in these acts of UK law are controls on how personal information must be stored and used by organisations, such as the NHS and government departments.

36. Thus, everyone in the NHS is responsible to follow the ‘data protection principles’, which state information must be relevant and accurate and kept up to date and should also be held securely to stop unlawful processing or access.

37. The Health Ombudsman can investigate aspects of record keeping, but it is not our role to reach determination where a breach of the act of law has occurred. To reach a view on this Mrs Y would need to take her concerns to the ICO, and if she is not happy with their ruling the next stage would be to challenge this through the court of law.

38. The ICO is the UK’s independent authority responsible for upholding information rights on data handling.

39. The Parliamentary and Health Service Ombudsman can consider complaints regarding the ICO’s function but where claimed failings of unlawful data manipulation or breach of data present, we would not be placed to comment on matters.

40. Though the Parliamentary and Health Service Ombudsman can investigate complaints brought to us regarding the ICO, we note that we are limited to what parts of the ICO’s function we can consider. For example, should a complainant be seeking to challenge an ICO decision or action this may need to be challenged through a judicial review or the court of law. In essence, though we can consider the ICO in remit, our consideration would be looking at their processes such as undue delays in their service, failure to follow procedures or administration and service.

41. As the complaint part relates specifically to an allegation of wrongfully manipulating and breaching data protection (in line with the GDPR data principles) Mrs Y would need to raise this matter to the ICO for their consideration.

42. For those reasons we would take no further action on this complaint part.

43. We have next addressed the following issues together owing to the outcome sought

• provided discharge letter with missing information • wrongly left her partner on co-careldopa for longer than needed • placed her partner on legal safeguarding for patients, who do not have capacity, so they could give him medication without having to discuss it with herself • did not provide a follow up appointment after her partner was discharged in August 2023 • failed to provide care to treat encephalitis.

44. In the complaint form to the Ombudsman, Mrs Y stated as an outcome to these points she is seeking the Ombudsman to review care and from this for a correct diagnosis to be made.

45. We sent the scope of complaint to Mrs Y on 23 June 2026 and received an agreement to this scope on 7 July 2026.

46. When considering if to seek clinical advice, we applied reasoning from our own service model and engaged again with Mrs Y to ensure we are clear on the distinction between Mrs Y wanting an independent review for answers or an independent clinical review that would then yield a different diagnosis. The two are very different in our remedy consideration.

47. Based on Mrs Y’s response of 7 July 2026, we take this as evidence and confirmation.

48. Our service model sets out the actions we must take in situations like this. Contained in section 3.10 it states:

There will be occasions when we decide that there are other reasons why we should not investigate a complaint made to us. These include if:

• the outcome sought is not achievable • an investigation would not be practical, would not reach a satisfactory conclusion and there would be no value in providing that response through an investigation.

49. On occasions complainants seek remedies that are not suitable for us to achieve under the powers we have under the Health Service Commissioners Act of 1993. Examples can include:

• expediting on a waiting list • prescribing medicines • providing a diagnosis or altering a patient’s diagnosis

50. Consistent with how we conduct our investigations we reached out a second time, on 9 July 2026, to ensure we fully understand the context of the review, which Mrs Y sought, and her reasoning and linkage to seeking a diagnosis.

51. From doing so, we are aware of the reasons as to why Mrs Y seeks this is for clinical or medical input to facilitate a diagnosis.

52. On that basis we consider there is no value in doing so as even if we were to, we cannot apply that consideration to changing her partners diagnosis or coming to a different view on their health condition.

53. We are satisfied this to be the reason for Mrs Y seeking a review after qualifying this twice and on that basis use the Ombudsman’s general discretion regarding this complaint part and take no further action

In Summary

54. As stated above, we are unfortunately unable to investigate the complaint brought to us by Mrs Y.

55. We recognise the impact on Mrs Y’s own emotional and mental health during this period and the impact of acting as the carer of her partner and her son. We recognise the stress which this whole process will have caused her, as well as the worry and anxiety that she has had regarding her partner’s condition. We also recognise that this has been a stressful time for Mrs Y’s family.

56. We recognise how her partner’s health has been impacted since 1997 to the present day, in which she believes that things are missing or have been omitted from her partner’s medical records.

57. We thank Mrs Y for bringing her complaint to us and we understand that the decision we have come to will be disappointing for her.

58. We hope that we have explained the thorough consideration we have given to our decision and the reasons have been clearly outlined.

1. We have carefully considered Mrs Y’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust). We are sorry to learn of the concerns Mrs Y raises about the issues with her partner’s care and the negative impacts this has had on her life, her partner’s life and the lives of their family.

2. We recognise Mrs Y’s partner has experienced ongoing health issues and Mrs Y herself has experienced issues regarding the care she has had to give to her partner. She has told the Ombudsman how the lack of a correct diagnosis for her parter is fuelling her worries for the health of her children and about her claims that her partner’s medical records have been altered and they do not show a true record of her partner’s health.

3. We have carefully considered Mrs Y’s complaint about the Trust. We have decided that as some aspects relate to allegations of a breach of the Data Protection Act, the complaint would be better suited for investigation by the Information Commissioner’s Office (ICO).

4. Regarding the other points, after clarifying further with Mrs Y the outcomes sought it is the Ombudsman’s view these cannot be achieved. As such, in line with our guidance on outcomes not achievable, we can take no further action.

5. We recognise this will be a disappointing decision form Mrs Y and our statement provided here gives reasoning to this decision