Call back requests
13. Mrs C tells us the ICB failed to return any of her call back requests.
14. In its response of 18 March 2024, the ICB explained that it aims to maintain open lines of communication and ensures that family members are fully involved throughout the process. The ICB advised that a member of staff attempted to return Mrs C’s call, although it acknowledges that there is no recorded evidence of these attempts.
15. The ICB explained the staff member recalls making calls from multiple locations, some of which may have displayed as a private number. The ICB recognised that its communication in this instance fell short of the expected standards and offered its sincere apologies.
16. The Nursing and Midwifery Council (NMC) Code (2015): The NMC Code sets standards for nurses, including practice nurses, to ensure they deliver safe, effective, and responsive care. One relevant principle is prioritising people, which includes effective communication with patients. While the Code does not dictate timelines, it emphasises accountability and respect for patient needs.
17. It seems on this occasion the ICB did not act in line with the NMC’s Code with regards to its level of communication with Mrs C. We can see the ICB has acknowledged its service fell below the expected standard.
18. Our ‘NHS complaints standards’ (December 2022) say we expect organisations to ‘support and encourage staff to be open and honest when things have gone wrong.’ It is also important ‘staff recognise the need to be accountable for their actions.’ Finally, our standards say when an organisation investigates a complaint it should ‘explain why things went wrong and identify suitable ways to put things right for people. Staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.’
19. Mrs C explained that her primary reason for bringing this complaint to our attention was to ensure the ICB learns from its mistakes. She expressed concern that a similar error could occur in the future and sought reassurance that appropriate measures had been taken to prevent a recurrence. We fully understand why Mrs C feels so strongly about her experience. It is clear that this was a deeply distressing situation for her, and we are sincerely sorry for the upset it has caused.
20. On 9 June 2025, we contacted the ICB’s complaints team to request evidence of any service improvements implemented as a result of Mrs C’s complaint. In response, the ICB provided an update outlining the changes made and confirmed that all relevant learning points had been discussed during a team meeting. Additionally, the Head of Continuing Healthcare offered further assurance by confirming that complaints and related learning are now a standing item on the agenda at monthly team meetings.
21. We consider the ICB has acted in line with our NHS complaints standards. It has undertaken further work to ‘identify suitable ways to put things right’. It has made wider service improvements, to change its process and support its staff to minimise the risk of similar mistakes happening in the future. As such, we are satisfied we do not need to take any further action regarding this complaint. We would like to thank both parties for their time and effort during this process.
ICB unable to meet Mr A’s needs
22. Mrs C explains the ICB failed to inform her that it was conducting a CHC checklist assessment to determine her father’s eligibility for CHC.
23. In its response, the ICB expressed concern that Mrs C was not informed about the assessment until the day it took place. It acknowledged that she should have been notified as soon as there was any intention to carry out an assessment. It recognised Mrs C should have been given the opportunity to support her father and to be involved in discussions about his care.
24. NHS Continuing Healthcare Checklist Guidance says ‘the individual should be given reasonable notice of the intention to undertake the checklist and have the process explained to them. They should normally be given the opportunity to participate, along with any representative, to contribute their views.
25. Based on the evidence provided, it is clear that the ICB did not act in accordance with the NHS Continuing Healthcare Checklist guidance (2022). The guidance states that individuals and their representatives should be given reasonable notice of an assessment, have the process clearly explained to them, and be given the opportunity to participate.
26. In this case, Mrs C was not informed of the assessment until the day it was carried out, denying her the chance to support her father or contribute to the discussion about his care. This failure to involve her meaningfully represents a clear departure from the expectations set out in the national guidance. We can see the ICB has acknowledged its service fell below the expected standard.
27. Our ‘NHS complaints standards’ (December 2022) say we expect organisations to ‘support and encourage staff to be open and honest when things have gone wrong.’ It is also important ‘staff recognise the need to be accountable for their actions.’ Finally, our standards say when an organisation investigates a complaint it should ‘explain why things went wrong and identify suitable ways to put things right for people. Staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.’
28. Mrs C explained that her main reason for bringing this complaint was to help ensure the ICB learns from its mistakes. She was concerned that similar errors could occur again and sought reassurance that appropriate steps had been taken to prevent this. We fully recognise why Mrs C feels so strongly about her experience. This was clearly a very distressing situation for her, and we are sorry for the upset it caused.
29. On 9 June 2025, we contacted the ICB’s complaints team to request evidence of any service improvements made in response to Mrs C’s concerns. The ICB provided an update detailing the changes it had implemented and confirmed that the key learning points had been discussed at a team meeting. Furthermore, the Head of Continuing Healthcare gave additional assurance that complaints and associated learning are now a standing item at monthly team meetings.
30. We consider that the ICB has responded in line with the NHS Complaints Standards. It has taken further steps to identify appropriate ways to put things right and has made broader service improvements to strengthen its processes and support staff—reducing the likelihood of similar issues happening again.
31. In light of this, we are satisfied that no further action is required from us in relation to this complaint.
Placement
32. Mrs C explains the ICB failed to consider the impact of potentially moving her father to a care home in Liverpool, 35 miles away from Manchester.
33. The ICB acknowledged Liverpool was discussed; however, this was only in the context of outlining what options were available. It explained that any placement decisions should be made in agreement with the family. While it is acceptable to discuss availability in a wider geographical area, it should have been made clear that there was no suggestion the patient would be moved to Liverpool. The ICB accepted that there appears to have been a breakdown in communication at this point. It apologised that the communication was not clear and reiterated its sincere apologies for any confusion or distress caused.
34. We refer to NHS Funded Nursing Care practice guidelines which state ‘placement decisions—such as choosing a care home—should be made with the person’s involvement and, where appropriate, with their family’s agreement. Decisions should be person-centred, with transparent rationale and explanation of options provided from the outset.’
35. On 9 June 2025, we contacted the ICB’s complaints team to request evidence of any service improvements made in response to the concerns raised by Mrs C. In its response, the ICB provided an update detailing the actions it had taken, including confirmation that the key learning points identified from this case were discussed at a team meeting.
36. To further strengthen its approach, the Head of Continuing Healthcare also confirmed that discussions of complaints and related learning have now been formalised as a standing item on the agenda at monthly team meetings. This change is intended to support continuous learning across the team and help prevent similar issues from occurring in the future.
37. In light of this, we are satisfied that no further action is required from us in relation to this complaint.
38. We recognise that Mrs C would like a financial remedy. However, we consider that the ICB has taken appropriate steps to put things right, in line with our complaint standards. These actions appear to address the issues raised and demonstrate a reasonable effort to acknowledge the impact on Mrs C and prevent similar occurrences in the future.
39. We hope our decision provides Mrs C with reassurance that the ICB has taken her concerns seriously, and that positive changes have been made at the ICB as a result of her complaint.