24. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. we do this by comparing what should have happened with what did happen.
25. If what happened fell far short of what should have happened, we call this a failing. When we see indications of a failing, we next look at whether that failing had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.
Concerns about the IRP’s decision making
26. Mrs A has brought specific concerns to us which we have considered together, as they link to the decision making of NHS England’s IRP. We will consider overall whether NHS England reached its decision in the right way.
27. Before we go on to discuss our decision, we would like to explain some information about how an IRP reaches its decision and what this means for how we look at it.
28. Whether an individual is eligible for CHC funding is a discretionary decision. It is our role to decide if the IRP made its decision in line with the National Framework.
29. We cannot question discretionary decisions when they have been made without maladministration (fault) and we can only uphold a complaint about an eligibility decision if there is some specific fault in the way the IRP reached its decision. Such decisions are based on clinical judgements and opinions. The fact someone else has a different opinion does not mean that there must have been a fault in the decision making process.
30. The purpose of the IRP is to review the procedure followed by the ICB in making a decision about a person’s eligibility for CHC. In reaching a view about whether the ICB followed the correct process, and whether it correctly applied the eligibility criteria, the IRP can recommend that the case be reconsidered by the ICB. This will address any faults identified in the process. It can also reach a view as to whether the individual should or should not be considered to have a primary health need.
31. When we look at a complaint about an IRP, we consider whether it took account of all the relevant information provided to it in reaching its decision.
32. To help us reach a decision there are four key areas we consider.
33. Firstly, we look at whether the IRP established all the obvious, appropriate, and relevant clinical facts.
34. We have carefully considered the information provided by NHS England. The IRP report shows that the panel considered the verbal contributions from the ICB as well as Mrs A. This is evidenced throughout the report.
35. We can see the IRP also considered the case summary, continuing healthcare assessment documents, care home records, hospital records and General Practitioner (GP) records when reaching its decision.
36. The panel also considered which domains Mrs A disputed and the reasons why. In section five, the panel notes Mrs A’s reasons for requesting an IRP meeting. It included considering the process followed by the ICB and considering the eligibility criteria for CHC funding.
37. We can see evidence of the IRP considering Mrs A’s concerns relating to the procedure followed in the IRP report. There were also documented discussions about Mrs I’s CHC eligibility.
38. We consider NHS England’s approach to be in line with Annex D: Independent Review Panel Procedures specifically section 2 which states:
‘An IRP’s key tasks are, at the request of NHS England, to conduct a review of the following:
a) the primary health need decision by a CCG [ICB]; or
b) the procedure followed by a CCG [ICB] in reaching a decision as to that person’s eligibility for NHS continuing healthcare and to make a recommendation to NHS England in the light of its findings on the above matters’.
39. Mrs A has brought concerns to us specifically relating to the eligibility criteria that has been considered and therefore, this is what our focus will be through the report.
40. We can see from the IRP report, and the notes from the meeting held in January 2021 with Mrs U, Mrs A, the ICB and NHS England, that the IRP had a detailed discussion about Mrs I’s needs. It allowed the family to openly discuss her needs and any concerns they had for each domain and key indicator.
41. We can see the panel took into account Mrs A’s concerns throughout its considerations and allowed further submissions to be made. This is evidenced by referring to Mrs A and Mrs U’s submissions in the report.
42. From the IRP report, we can see Mrs A disputed the weightings for the nutrition food and drink, skin, mobility, and behaviour domains, as well as the four key indicators.
43. For each domain and key indicator, the panel discussed Mrs A’s submissions and her reasons for disagreeing with the domain or key indicator. It also took into account the ICB’s submissions. The IRP then went on to consider the submissions when reaching a decision.
44. Based on the above, we cannot see any obvious omissions in the documents which NHS England has provided. We are of the view that NHS England obtained all available and relevant records to reach a robust decision. We have reviewed the records and can see it considered these as part of its decision. We cannot see any indication of failings in this part of IRP’s consideration which would lead us to question its decision.
45. Secondly, we consider whether, prior to reaching its decision, the IRP had an appropriate clinically led discussion of the impact and interaction of the relevant clinical facts.
46. We can see from the IRP report there was an appropriately constituted panel. This included the Chair, a ICB representative, a clinical adviser to support the panel with clinical matters and a local authority representative present to advise on social care issues. We consider this to be in line with paragraph 200 of the National Framework which states:
‘NHS England is responsible for convening independent review panels consisting of:
· An independent chair (appointed by NHS England)
· A CCG (ICB) representative (who is not from the CCG that made the decision which is the subject of the review)
· A local authority Social Services representative (who is not from a local authority where all or part of the CCG (ICB) involved in the decision is located).
47. The IRP worked through each of the domains in turn and discussed these with the ICB, Mrs A and Mrs U. This was cross referenced with information in the records. It recognised Mrs U’s account, alongside the medical evidence, when reaching a decision for each of these.
48. The report shows a clinically led discussion of the key facts took place. The IRP explained the evidence it used to inform its decision making. The IRP has explained the reasons for its views on the levels of need for each of the domains. It has explained how it considered the ICB’s evidence, Mrs A and Mrs U’s submissions, and the records regarding each domain.
49. We have seen no evidence to suggest any facts were overlooked, marginalised, or not adequately considered during the IRP process. For this reason, we have seen no indications of failings in this part of the IRP’s process.
50. Thirdly, we consider whether the IRP’s final decision adequately considered and explained the conclusions of the clinically led discussion.
51. We can see from the report there is evidence of a detailed discussion and consideration of the four key indicators (nature, intensity, complexity, and unpredictability). The four key indicators may alone or in combination demonstrate a primary health need because of the quality and/or quantity of care that is needed to meet the individual’s needs. The IRP considered how each of these impacted on Mrs I’s needs in turn.
52. Mrs A has not detailed any specific concerns relating to each domain but has provided reasons for disputing the four key indicators, which we will consider in question four below.
53. Paragraph 13 of Annex D: Independent Review Panel procedures says:
‘On the basis of the evidence received and the advice given at the IRP, the chair should be able to determine, in consultation with other IRP members, whether eligibility criteria have been correctly applied. The chair should have the capacity to make balanced decisions.’
54. Based on our review of the report, we can see the panel acknowledged and discussed the views of the ICB, Mrs A, Mrs U, the clinical advisor, and local authority representative. It is evident from the report and the meeting notes that these submissions were taken into account when reaching a decision.
55. In addition to this, we have carefully considered the medical records. Having considered the IRP report, available evidence, the family’s submissions, and the IRP’s conclusions, we consider the rationales in the domains can be supported, as explained above. They are consistent with the domain descriptors and in line with the National Framework, which will be discussed in question four further.
56. The IRP has provided a clear explanation for its views about Mrs I’s needs. It has used a variety of sources and evidence to show how it weighted each of the domains. It has detailed why its decision may differ to the ICB’s or Mrs A’s. The IRP explained in detail how it weighed up all the evidence and came to its decision. This was in line with the National Framework, and we cannot see any indication NHS England got anything wrong here. We have seen no indications of failings for this part of the IRP’s process.
57. Fourthly, we consider whether the IRP applied the appropriate eligibility tests. We also consider whether the IRP’s conclusions about them were reasonable.
58. The report shows the panel discussed the four key indicators alongside their relationship with Mrs I’s daily needs.
59. We can see at the IRP meeting that the panel considered each of the key indicators in line with Mrs I’s needs. We will consider the IRP’s conclusion on each key indicator below.
Nature
60. The National Framework says, ‘Nature refers to the type of needs, and the overall effect of those needs on the individual, including the type (“quality”) of interventions required to manage them’.
61. The National Framework provides some questions that professionals can consider when looking at the nature indicator. These are listed on page 96 of the National Framework and include:
· ‘How does the individual or the practitioner describe the needs (rather than the medical condition leading to them)? What adjectives do they use?
· What is the impact of the need on overall health and well-being?
· What types of interventions are required to meet the need?
· Is there particular knowledge/skill/training required to anticipate and address the need? Could anyone do it without specific training?
· Is the individual’s condition deteriorating/improving?
· What would happen if these needs were not met in a timely way?’
62. We understand Mrs A has concerns that Mrs I could not physically or mentally do anything for herself, except when prompted. She could get food and drink from her plate/move the cup to her mouth. Mrs A also says Mrs I was either in her chair or bed, and if she moved, she would have fallen.
63. She also says Mrs I had a history of repeated hospital admissions with cellulitis and was at a high risk of skin breakdown.
64. She says her behaviour was only managed because of the prescribed antipsychotic medication. If not prescribed she would be at a risk of self-neglect and would have caused her to be anxious, uncooperative, and aggressive.
65. Mrs A also says Mrs I needed constant waking supervision and interventions from skilled nursing staff. At night she was confined by bed rails and had an alarm sensor, which detected movement.
66. Mrs A also tells us that in June 2019, the residential care home notified Mrs A that it was no longer able to care for Mrs I’s needs due to her worsening cellulitis and behaviour. An emergency hospital admission followed on in July 2019 and she was hospitalised for eight weeks. The hospital mental health recommendation was ‘EMI placement with oversight from a registered nurse to plan, implement and evaluate ongoing complex care needs taking into account previous history, current presentation and ongoing complex care needs associated with moderate/advanced dementia’.
67. EMI homes specialise in care for older people with a mental illness or disorder.
68. We can see from the IRP report, that the panel considered Mrs A’s submissions, as detailed above, during its consideration. The panel acknowledged that Mrs I had a previous history of vascular dementia and leg ulcers. She also suffered from anxiety, low mood and agitation which resulted in her being both verbally and physically aggressive during care delivery. The IRP also considered her mobility and risk of falls.
69. The panel found that Mrs I could not work unaided and required the use of a wheelchair. Prior to this when she resided at a care home, she was able to walk with a Zimmer frame. She was unable to mobilise or co-operate due to her comorbidities of vascular dementia and was totally dependent on care home staff to mobilise. This was with the aid of one of two members of staff. She was also assessed as a high risk of falls, but Mrs I did not sustain any falls at the time of the review period. The panel acknowledged that sensor mats and bed rails were in place to reduce any risk of falls.
70. In relation to Mrs I’s medication, the panel found she was prescribed a range of medications for which the care home would have been responsible for monitoring their effectiveness and observing for any side effects. IRP members considered that Mrs I’s medication regime required all her prescribed medication to be administered and monitored by the registered general nurse.
71. It also noted Mrs I had periods of agitation, anxiety, and depression. She had been seen and assessed by the Rapid Intervention Treatment Team (RITT) and was prescribed medication. The care home staff would have been required to have knowledge of how this may affect Mrs I’s daily care needs and to monitor her for any deterioration. It stated having acknowledged this, there was no evidence that essential care was not completed.
72. In relation to Mrs I’s skin, the panel recognised that her skin care created challenges for staff in meeting her needs. However, concluded that her skin responded to treatment, showed progress when in hospital and was fully healed at the time of the DST. The panel also concluded the records indicate there was no indications that the staff encountered difficulties in meeting her care needs in relation to this.
73. The panel agreed that Mrs I required 24-hour care in an environment that she could be kept safe in as well as supported with all activities of daily living. However, it concluded that the care she required could be delivered by care staff experienced in caring for elderly people with comorbidities. The panel agreed that at the time of the DST, staff delivering the care did not require any additional skills beyond that which would be expected, routinely, of all staff working in such a setting.
74. It found there was nothing in the quality and type either of Mrs I’s care needs, or the care she required to meet these, that went beyond the level of care that a Local Authority could lawfully provide with the support of NHS funded nursing care and community health services such as her GP and the RITT. IRP members therefore agreed that the nature of Mrs I’s care needs did not demonstrate a primary health need.
Our consideration
75. We appreciate Mrs A’s submissions that her mother suffered with dementia and cellulitis, however NHS England’s approach in focusing on the impact of this on Mrs I’s daily needs is in line with paragraph 62 of the National Framework, which says: ‘eligibility for NHS Continuing Healthcare is a decision based on an individual’s assessed needs. The diagnosis of a particular disease or condition is not in itself a determinant of eligibility for NHS Continuing Healthcare’.
76. In relation to Mrs A’s concerns about Mrs I’s behaviour, we have carefully reviewed the records. We can see the records support the panel’s view that Mrs I did present with some challenging behaviour, however there is no evidence to suggest that this caused a barrier in staff being able to deliver personal care task.
77. From a review of the records, we have seen some entries of challenging behaviour, specifically on 3 and 5 September 2019, however there is no evidence to suggest that this caused a barrier to staff carrying out personal care tasks for Mrs I. We can see evidence that staff were able to encourage Mrs I or use the ‘retreat’ method to calm Mrs I.
78. We can see on the pre-admission assessment form, under medication it states, ‘can refuse, staff usually come back later’. The records also include several examples of successful care being provided to Mrs I such as ‘30 August 2019-‘accepted medications with encouragement’ from the hospital entries, and ‘3 September 2019- ‘Accepted assistance with all required needs, became mildly verbally hostile towards staff when support offered. But settled quickly’ from the care home, as examples.
79. We have seen also seen evidence that Mrs I received input from the Rapid Intervention and Treatment Team in July 2019 while in hospital. However, this was prior to the reviewed period. Mrs I remained on the prescribed Risperidone dose of 250mg throughout the review period. This was to manage her agitation. We have seen no evidence to suggest that during the review period, there were changes to the medication. This suggests the medication was managing her condition. We can see from the records Mrs I was discharged from the RITT team during the review period on 30 August 2019.
80. This would support the IRP’s rationale that although there were episodes of some challenging behaviour this did not present with any difficulties for the nursing/hospital staff to manage.
81. We have seen no evidence of further specialist interventions, such as mental health services that would suggest staff were unable to provide the necessary care and treatment for Mrs I because of her behavioural needs. We consider this to support the panel’s conclusions of the same.
82. In relation to Mrs A’s concerns that the RITT recommendation was for Mrs I to be placed in an EMI placement with input from a registered nurse to manage Mrs I’s needs. From the records we can see this was in July 2019 (prior to the review period). We also understand Mrs I’s care was overseen by a registered nurse in line with the RITT recommendations during the claim period. Based on this we can see the panel concluded Mrs I was eligible for NHS funded nursing care and therefore its decision making was in line with paragraph 246 of the National Framework which states:
‘NHS-funded Nursing Care is the funding provided by NHS to care homes with nursing, to support the provision of nursing care by a registered nurse for those assessed as eligible for NHS- funded Nursing Care’.
83. We have also seen the panel acknowledged that during the claim period Mrs I was able to eat and drink independently, but sometimes did need prompting. We can see from the records, she was seen by the dieticians on 21 and 29 August 2019. However, no concerns were raised as she was increasing in weight but was given fortified drinks because of her swallowing concerns. The records show an increase of weight from 46.5kg on 8 August 2019 to 51.45 kg on 2 September 2019.
84. In addition, we can see the panel considered concerns that Mrs I was at a risk of falls, however from the records we can see there were no falls recorded during the review period.
85. In addition, a sensor alarm and bed rails were in place, which was within the scope of care that the nursing home was expected to provide. This would support the decision making of the IRP panel that Mrs I’s needs were not beyond that which the local authority would be expected to provide.
86. In relation to Mrs I’s skin, we have seen evidence that she had a history of leg ulcers and cellulitis which did require dressings and antibiotic therapy. From the records we can see evidence that she did respond to the treatment and her care for this was being managed by the registered nurse. We note the staff were expected to provide preventative intervention and assess Mrs I’s skin. However, there is no evidence to suggest that there were any difficulties in managing or providing this care. This is evidenced by no input from specialist care or changes to care plans/medications. This would support the IRP’s decision making and rationale that care was being managed by the nursing staff.
87. Overall, we have found there are no indications of failings in the IRPs decision making for this indicator. We find the records suggest Mrs I’s needs were not outside of that expected from the care home setting. There is no evidence to suggest care staff could not deliver the care or the changes to this that were required.
88. We can see the IRP considered relevant areas for the ‘nature’ key indicator and have seen the IRP’s conclusions are supported by the records.
Intensity
89. The National Framework explains that ‘Intensity’ is about the quantity, severity, and continuity of needs.
90. From the report, we can see the panel considered the quantity and degree of Mrs I’s needs. It also considered the support that was required to meet these, including the need for ongoing care.
91. We find the panel considered key questions that are outlined in the National Framework which include:
· ‘How severe is this need?
· How often is each intervention required?
· For how long is each intervention required?
· How many carers/care workers are required at any one time to meet the needs?
· Does the care relate to needs over several domains?’
92. Mrs A raises concerns that her mother had a primary health need based on the intensity of these needs. Specifically, she says this was because of her deteriorating health which meant that she could not physically or mentally do anything for herself. She also says Mrs I required interventions several times a day for her skin integrity. She also says Mrs I required supervision during all waking hours as she would get up several times unaided.
93. The IRP acknowledged that Mrs I required the assistance of two carers for all her daily care needs. She also needed prompting at mealtimes. She also needed to be comforted and reassured when taking medication. It found that Mrs I’s care needs meant that these interventions had to be delivered regularly throughout the 24-hour period.
94. The IRP noted that the daily care home records reported that Mrs I was sometimes non-compliant with her care needs and that she was on medication for her agitation. It also accepted that she was incontinent of urine and faeces and required her personal hygiene to be attended to. When Mrs I displayed challenging behaviour, the staff at the nursing home were able to manage this.
95. It therefore concluded that Mrs I did not require sustained and continuous care and that her needs were not at a level of intensity to indicate a primary health need.
Our consideration
96. Having reviewed the records, we find no evidence to suggest Mrs I’s needs could not be addressed straightforwardly by resources available in the nursing home, which included oversight from the registered nurse. We can see the panel took into account that Mrs I was on medication, however we have seen no significant changes to care plans or medications following this during the claim period. This would suggest her care was being managed.
97. We find the IRP’s rationale and decision making is in line with the National Framework. From a review of the records there was no evidence of care being needed by Mrs I outside of the planned interventions. She required the support and assistance of two carers for personal and hygiene care and there is no evidence to suggest that particular strategies were required to deliver this care.
98. We have seen evidence in the records to show two carers were needed. An example is included in the resident profile which states under personal care needs, ‘I need two staff to assist me’.
99. We recognise that Mrs I did present with challenging behaviour during the claim period, however staff were able to reassure and manage this. We can see the panel acknowledged that this meant sometimes personal care would take longer than planned however, we have seen no evidence to suggest that this had an impact on the outcome. It did not cause a barrier in carrying out Mrs I’s necessary personal and hygiene care.
100. We can see the IRP reviewed the records and reached its conclusions in line with the National Framework. The panel looked at the totality of the needs when reaching its conclusions. This is in line with the Department of Health and Social Care, NHS Continuing Healthcare Decision Support Tool guidance. Paragraph 33 states:
‘In all cases, the overall need, the interactions between needs in different care domains, and the evidence from risk assessments should be taken into account in determining whether a recommendation of eligibility for NHS Continuing Healthcare should be made’.
101. Further to our considerations, we have seen no indications of failings in the decision making of the IRP when considering the intensity key indicator. We find it has reached its decision with reference to the records and in line with the National Framework.
Complexity
102. The National Framework says, ‘complexity refers to how the needs arise and interact to increase the skill needed to monitor and manage the care’.
103. Mrs A tells us that Mrs I could become uncooperative and difficult when she was aggressive and ‘lashed out at staff’. She says it meant that her needs were more complex.
104. The report shows the IRP noted there were certain interactions between various domains. Such as her cognition impacting on her communication, psychological and emotional needs, and behaviour. Also, her skin was affected by her level of mobility and continence needs.
105. Despite this interaction there was no evidence this caused the needs to be so complex that, overall, her needs could not be managed, or that it resulted in a problematic situation. Most of Mrs I’s care was provided by the carers following relevant care plans for each aspect of her care.
106. The IRP says it did not identify any evidence that staff needed additional skills, knowledge, or experience beyond that which would be expected for all staff caring for older people with comorbidities in an EMI setting.
107. The IRP noted that Mrs I was cared for by her GP and assessed by the RITT team for her psychological and emotional health and behavioural needs, she was discharged during the claim period on 30 August 2019. She was also seen by the dieticians while in hospital. It also noted due to her cellulitis she required district nursing input, however during the claim period and prior to the DST being completed Mrs I did not have cellulitis and did not require specialist treatment.
108. However, despite the above interactions the IRP found no evidence to suggest that Mrs I required access to highly trained staff or to a healthcare team with specialist skills, to minimise harm or to reduce the risk of unnecessary deterioration.
Our consideration
109. We consider the IRP’s conclusions were in line with the National Framework which provides questions that professionals can consider in considering this indicator:
· ‘How difficult is it to manage the need(s)?
· How problematic is it to alleviate the needs and symptoms?
· Are the needs interrelated?
· Do they impact on each other to make the needs even more difficult to address?
· How much knowledge is required to address the need(s)?
· How much skill is required to address the need(s)?
· How does the individual’s response to their condition make it more difficult to provide appropriate support?’
110. We have also reviewed the records in relation to the dietician’s input we understand Mrs I was seen on 21 August 2019 and 29 August 2019 due to her swallowing concerns. She was given fortified drinks, however there were no concerns following this. This is also evidenced by Mrs I’s weight progressively increasing.
111. In relation to Mrs I’s challenging behaviour, we can see she was prescribed Risperidone to manage her agitation. There is no further evidence that Mrs I required any unplanned support or advice from more specialist staff to meet her daily care needs. For example, there is no evidence of active involvement from mental health services or the need for Pro Re Nata (PRN which means as of when is needed) medication. This would suggest her needs were successfully being managed by the resources available in the EMI setting.
112. There is no evidence to suggest her needs caused complex interactions which resulted in needs being difficult to manage. The records show staff were generally able to successfully carry out personal hygiene tasks.
113. We have seen no evidence of further specialist inventions and throughout the claim period there is no evidence of further input required from skilled or specialist professionals. Instead, the staff used methods such as reassuring Mrs I, or the ‘return and retreat’ method to carry out tasks.
114. Having considered the above, we find no indications of failings in the decision making of NHS England. Having reviewed the records, we find no evidence to suggest an interaction between the needs which led to an increase in the level of skills or knowledge or carer time that was required. We are satisfied the IRP has considered the complexity indicator in line with the National Framework and has based its decision in line with the records.
Unpredictability
115. The National Framework sets out that unpredictability is concerned with the degree to which needs fluctuate, thereby creating challenges in meeting them on a day-to-day basis.
116. We understand the family has concerns that Mrs I required supervision during all waking hours, as she would get up several times unaided. Mrs A says both professional EMI nursing staff and skilled EMI care staff’s knowledge and skills were needed to manage this.
117. The IRP accepted that care home staff would not be able to know in advance when Mrs I would be incontinent, develop cellulitis or display challenging behaviour. However, it says when such incidents did occur, staff were able to respond by following a regime of care. This care regime was established after only eight days, as the DST was completed eight days after Mrs I’s admission at the nursing home.
118. The IRP found that Mrs I’s care needs could be readily predicted by staff and appeared to be broadly stable at the time of the DST. It also noted that during periods of challenging behaviour staff had to place Mrs I in a slightly higher degree of monitoring, such as to monitor the effect of the medications, but there was no evidence to suggest staff ever having to act spontaneously or outside planned care interventions.
Our consideration
119. Based on the above, we can see the IRP looked at how Mrs I’s needs fluctuated and the likely changes this created in managing them. The IRP’s consideration looked at key questions in the National Framework which are:
· ‘Is the individual or those who support him/her able to anticipate when the need(s) might arise?
· Does the level of need often change? Does the level of support often have to change at short notice?
· Is the condition unstable?
· What happens if the need isn’t addressed when it arises? How significant are the consequences?
· To what extent is professional knowledge/skill required to respond spontaneously and appropriately?
· What level of monitoring/review is required?’
120. We have reviewed the information available, including Ms A and the IRP’s submissions as well as the records. Based on this, we have seen no evidence that Mrs I’s needs were so unpredictable that they were difficult to manage and therefore the records support the IRP’s rationale.
121. We acknowledge Mrs A’s submissions that her mother’s behaviour was unpredictable. However, we can see the IRP found the timing of the incidents was unpredictable, but Mrs I’s needs, and how they were managed, was not unpredictable.
122. Having reviewed the available evidence, we acknowledge that Mrs I did present with challenging behaviour during the claim period, however there were no changes to care plans or medications, which would suggest staff were able to predict her behaviour and manage it accordingly. There was no evidence that Mrs I’s level of support changed frequently or at short notice.
123. We have seen nothing to suggest that her needs changed or fluctuated significantly on a day to day basis.
124. In summary, Mrs I required carers who could anticipate and manage risks and her wellbeing, but the ability to recognise and prepare for those care needs were not of a level of skill or knowledge above what could be expected of a local authority.
125. We find the records support the IRP’s rationale that there were no sudden or critical changes in the care responses that were required, and skilled interventions were not needed, other than the RITT intervention. The IRP stated there was no unpredictability regarding Mrs I’s wellbeing.
126. Based on the above consideration, we have seen no indications of failings in the decision making of NHS England. The IRP considered this key indicator in line with the National Framework. It considered the records to identify if any interventions were required. We find the IRP’s conclusions are in line with the National Framework and are supported by the records.
Conclusion
127. We have carefully considered the information that Mrs A, Mrs U and NHS England have provided to us. We find there are no indications that something has gone wrong in this complaint.
128. We appreciate Mrs A has been pursuing her concerns for a long time and that doing so has caused her frustration and distress. We were sorry to learn of the concerns and hope that our thorough explanations provide reassurance that the right process has been followed.