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NHS England

P-001375 · Statement · Decision date: 26 April 2022 · View NHS England scorecard
Complaint (AI summary)
Mr T complained NHS England's independent review panel incorrectly denied his mother continuing healthcare funding, disputing the assessment of various care domains.
Outcome (AI summary)
Closed. The complaint was outside the ombudsman's time limit, and insufficient evidence was provided to set this aside.

Full decision details

The Complaint

3. Mr T complains on behalf of his mother, Mrs T, about the outcome of the NHS England independent review panel and its decision she was not eligible for continuing healthcare (CHC) funding on 29 January 2020.

4. He says it did not correctly assess the domains of behaviour, mobility and nutrition, and the key characteristics. He says the IRP over relied on Mrs T’s needs being well managed.

5. He says her estate has been prevented from having a full and proper assessment of her eligibility for continuing healthcare funding, which has meant the family has not been able to recover care home fees that were paid incorrectly.

6. He would like a finding that establishes Mrs T was eligible for continuing healthcare funding.

Background

7. Mrs T lived in a nursing home from 18 November 2006, until she died on 31 July 2013.

8. NHS Sheffield Clinical Commissioning Group did a retrospective Decision Support Tool (DST) in January 2017 and found Mrs T was not eligible for CHC funding. Mr T, through a law firm, appealed this decision on 14 June 2017. This upheld the previous decision.

11. The law firm requested an independent review of this decision on 28 March 2018. The IRP was held on 29 January 2020, and it emailed its decision to the Advocate on 5 March 2020.

12. On 4 March 2021, the Advocate sent the independent review panel (IRP) report to us. On 11 March 2021, it sent a complaint form to us about the IRP’s decision.

Findings

14. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason. We have contacted the Advocate to ask for information to help us to understand the reasons why it could not bring his complaint to us sooner.

15. We can see NHS England sent the Advocate the findings of its IRP by letter and email on 5 March 2020.

16. The Advocate sent a copy of the IRP and the decision letter to us on 4 March 2021. This was the last day possible for submission to be within a year of the date of knowledge. Our intake team informed the Advocate, on 10 March 2020, that it had not sent a complaint form to us. The Advocate resent its email and attachments to us on 10 March.

17. The Advocate sent a complaint form to us on 11 March 2021. This was more than a year since it had received the IRP’s decision. The complaint is out of time by seven days.

18. The complaint form also says it had complained to the relevant organisation on 28 March 2020. The next stage in the complaint procedure, for continuing healthcare funding complaints, is to come to us, so it is unclear who this complaint was made to.

19. We can put aside the time limit if we believe there are reasonable causes. When deciding if we should apply our discretion, we must consider the reasons the case has been delayed in reaching.

20. We asked the Advocate to explain why it had not sent the complaint within a year, and to give us further information about the complaint it said it sent on 28 March 2020.

21. The Advocate said it received the IRP decision form and letter on 27 March 2020. It said it contacted us and we acknowledged this as a complaint on 4 March 2021. It says our intake team contacted it on 10 March: ‘stating they had not received the documents in support of the complaint form (?!) which we confirmed we had sent 5/3/21. As requested, we resent the support documents’.

22. The Advocate says we contacted it again on 11 March 2021 to say we did not have the original complaint form. When asked, it says it then sent us the complaint form again.

23. We can see from the records NHS England sent the IRP decision and report to the Advocate by letter on 5 March 2020. We have no reason to disbelieve it when it says it did not receive the letter until 27 March. We do not know why it took over three weeks to reach the Advocate by post. But we can see NHS England emailed them the decision on 5 March 2020. This means the Advocate’s date of knowledge is 5 March 2020.

24. Our records show the Advocate emailed us on 4 March 2021. That email says: ‘Please find attached IRP outcome letter and report.’. There is no reference to a complaint form in the email, nor was one attached to it. There was no other information in the email. We sent our standard confirmation email that we had received this. The Advocate’s email from 4 March 2021 therefore was not a complaint. We did not receive a complaint until they submitted a complaint form on 11 March 2021.

25. A complainant does not need to make a complaint to NHSE about an IRP decision, they can bring it straight to us. The Advocate has given no reason why it could not send us the complaint within a year of it getting the IRP decision.

26. Based on the information we have received, we have seen no reason for us to put the time limit aside for this complaint.

27. We understand this is likely to be disappointing for Mr T. We appreciate his mother’s illness was distressing for him and we would like to thank him for raising his concerns with us.

Our Decision

1. We have carefully considered Mr T’s complaint about NHS England. The complaint is outside our time limit. We have decided not to put the time limit to one side and will not be considering this complaint further.

2. Mr T requested an advocacy agency act on his behalf (the Advocate). We contacted the Advocate for more information about when it sent Mr T’s complaint to us. We have looked at the complaint and the rest of the information about it carefully. We have not seen sufficient evidence to allow us to put the time limit aside.

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