19. It is our role to decide whether NHSE’s IRP acted in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (2022) when it considered whether Mrs Z was eligible for CHC. The National Framework sets out the principles and processes ICBs and NHSE should follow when considering if someone is eligible for CHC.
20. We cannot consider the discretionary decisions the IRP made when it decided on eligibility. This includes the decisions it makes based on clinical judgement and clinician’s opinions. We can only consider if the IRP has followed the National Framework. This means we can only uphold a complaint about a CHC eligibility decision if we find the IRP did not follow the National Framework when it made its decision.
21. The IRP reviews if the ICB should have found the person to have a primary health need and therefore be eligible for CHC. It also reviews the ICB’s procedures when it was coming to its eligibility decision to make sure it was acting in line with the National Framework. If the IRP does find the ICB made a mistake, it can:
• recommend the ICB reconsiders if the patient had a primary health need, and • recommend the ICB addresses any procedural faults the IRP identified.
22. It is important to note that NHSE’s decision supersedes all previous eligibility decisions. Therefore, procedural issues only have a direct substantial effect on the overall eligibility decision in exceptional circumstances.
23. Moreover, our remit solely concerns the review of IRP’s decision-making process and whether it followed the National Framework in coming to its decision. We do not review the ICB’s original decision, nor can we comment on whether a different process should have been followed by the ICB. With regards to procedural issues raised by complainants, our role is to review whether the IRP adequately responded to the issues raised.
Did the IRP clearly explain how it had reached its decision?
24. Mr Z has told us he disagreed with how the IRP considered several of the domains the health service uses to determine a person’s care needs.
Breathing
25. Mr Z says the IRP incorrectly documented the family submitted no needs in this care domain. The family feels Mrs Z had a moderate level of needs in the breathing domain.
26. To see a weighting of moderate in this domain, the IRP would need to see the following:
‘Shortness of breath or a condition which may require the use of inhalers or a nebuliser and limit some daily living activities.
OR Episodes of breathlessness that do not consistently respond to management and limit some daily living activities.
OR Requires any of the following: low level oxygen therapy (24%).
room air ventilators via a facial or nasal mask.
other therapeutic appliances to maintain airflow where individual can still spontaneously breathe e.g. CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep.’
27. The ICB considered no needs, and the IRP agreed on low level of needs.
28. The DST describes low level of needs in the breathing domain as:
‘Shortness of breath or a condition which may require the use of inhalers or a nebuliser and has no impact on daily living activities.
OR Episodes of breathlessness that readily respond to management and have no impact on daily living activities.’
29. Mr Z explained in his written statement; the descriptor of low needs does not coincide with the evidence presented to the IRP. He said his mother had chronic obstructive pulmonary disease (COPD – a group of progressive lung disease) which impacted on her daily living activities as she became breathless when mobilised or tried to communicate.
30. The family told the IRP their mother would take a few short stops and then stop to get her breath.
31. The ICB representative told the panel during her assessment, Mrs Z did not come across she was breathless, and there was no evidence to confirm her breathlessness.
32. The IRP concluded Mrs Z’s assessed level of need for this domain match the low descriptor as she had episodes of breathlessness that responded to management and had no impact on her daily living activities.
33. In terms of the IRP incorrectly documenting the weighting, the IRP report shows under the breathing domain the family had provided no needs for this domain, and the LRM which took place on 18 March 2024 also records the family had agreed Mrs Z had no needs associated with her breathing. This is also supported by an email sent by Mr Z to the ICB, where there is no reference to Mr Z disagreeing with no needs within the breathing domain.
34. Our adviser explains applicants are at liberty to change their opinions about the level of need weighed against a care domain, and the IRP would need to provide why this was incorrectly recorded within the report. At this point, we cannot see anything went wrong here.
35. We have also considered the evidence relating to the breathing domain. Having reviewed this evidence, the care records do not document any concerns in relation to Mrs Z’s breathing. Our CHC adviser also states there is no care plan for breathing issues within the evidence.
36. While there were no records of care staff asking Mrs Z to sit down and rest due to shortness of breath, this was described by the care home at the LRM. The representative from the care home suggested Mrs Z is encouraged to sit and try not to exert herself. The care home also stated Mrs Z is encouraged to sit down and take a break when she seems to be out of breath. Our adviser says the IRP will have reviewed all the information within the case file and would have been aware of this.
37. We also considered the GP records, which do not show there was a diagnosis of COPD. We can see a salbutamol inhaler, and spacer was prescribed which was dated in December 2023. As this was after the period the DST was completed, this was not information which would have been available at the time the DST was completed.
38. The IRP increased the level of need within this domain from no needs to low, and our adviser says this was in acknowledgement of Mr Z and the care home’s verbal information about a COPD diagnosis, although no evidence exists to show this was formally diagnosed.
39. Our adviser explains the IRP also considered Mrs Z did have mitral valve regurgitation and atrial fibrillation (interconnected heart conditions) which may have contributed to shortness of breath at times.
40. We recognise Mr Z’s concerns about his mother’s needs in the breathing domain. We think the IRP acted in line with the National Framework when it considered Mrs Z’s needs in this domain. We have seen no indication of failings in how the IRP considered this domain.
Psychological and Emotional Needs
41. Mr Z considers Mrs Z’s needs should have been weighted as high in this domain.
42. The DST describes moderate needs in this domain as:
‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which do not readily respond to prompts, distraction and/or reassurance and have an increasing impact on the individual’s health and/or well-being.
OR Due to their psychological or emotional state, the individual has withdrawn from most attempts to engage them in care planning, support and/or daily activities.’
43. The DST describes high needs in the Psychological and Emotional Needs domain as the following:
‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, that have a severe impact on the individual’s health and/or well-being.
OR Due to their psychological or emotional state the individual has withdrawn from any attempts to engage them in care planning, support and/or daily activities.’
44. Both the ICB and the IRP assessed Mrs Z’s needs in this domain as moderate.
45. Mr Z informed the panel Mrs Z was prescribed an antidepressant to stabilise her mood. In the DST, it was noted his mother did not have a diagnosis of depression. The discussions took place around Mrs Z’s care home notes, which reflected low moods, and she was withdrawn. It was also noted she could become anxious, tearful and worried. She would become tearful and distressed when reminded of her husband’s passing.
46. The panel were informed the carers called Mr Z as his mother would not respond to them and would frequently get upset or distressed. As such, Mr Z would try to calm her down on the phone or visit the home when she was non-responsive.
47. The IRP reflected on the written evidence which noted Mrs Z preferred to be left alone, and she did not readily respond to reassurance. She also suffered from hallucinations, especially at night. It noted the input from the Older Adults Mental Health team was on 24 April 2022. While at the time of the DST she was not under them, the IRP said their recommendations would have remained in place.
48. The family informed the panel the care home noted Mrs Z’s poor sleep pattern, which meant she had a low dietary intake, and subsequent weight loss. This indicated her low mood increased her risk of malnutrition and dehydration. Mrs Z’s distress made her noncompliant with meals, personal care, and it impacted her engagement in social activities. The care home nurse noted her periods of distress occurred at least three to four times during the week, which were not prolonged but could consistently reoccur during the day.
49. Her room was described as quiet, with no TV or radio. Her family also told the IRP she did not have much furniture in her room due to her behaviour.
50. The panel highlighted the written evidence about Mrs Z being described as inconsolable at times when she was distressed, which resulted her in physically and emotionally shutting down, refusing help, and appearing unresponsive. It said the staff would leave her to settle and this took up to an hour and a half. It referred to one occasion when she refused one-to-one support and barricaded herself in the bedroom. Another example was when Mrs Z locked herself in another resident’s bedroom, who was on oxygen.
51. The family referred to guidance by the Alzheimer society (2014) which explained how individuals with severe cognitive impairments could actively withdraw. The family explained Mrs Z had several psychological and emotional needs which she was unable to deal with. The panel were informed Mrs Z had lost both her husband and her home, which led her to being traumatised. She also suffered from a pelvic fracture, which impacted her severely.
52. The family’s opinion was an individual could be severely impaired and be actively withdrawing from care. In Mrs Z’s case, the family felt she understood what she was withdrawing from, and she understood when she said no, and when she didn’t want anyone near her. Mrs Z was noted as eloquent about what she was saying which included she wanted people to get away from her.
53. The panel asked the family if Mrs Z made comments about wanting to die or to go home. The family confirmed her comments were a recurring theme, and she when said these comments, Mrs Z was distressed and unhappy.
54. The ICB representative commented when looking at cognition and psychological and emotional needs, it looks at whether Mrs Z had the ability to withdraw, and if she understood she was withdrawing from. The representative said in Mrs Z’s case, she kept asking where her husband was, and when she was informed, she had forgotten.
55. It said she became lucid, and her long-term memory would still be there. The representative said the question for Mrs Z was whether she understood the concept of ‘husband died’, or ‘I’m not going home, this is my home?’, and whether she understood she was not at home. The ICB representative said it would look at whether Mrs Z’s cognition was severely impaired or was there a level where she had that cognition and was able to understand all that was going on with her.
56. The IRP reflected on the written evidence which confirmed Mrs Z engaged with singing, reminiscing and looking through wedding albums. It mentioned an example of when Mrs Z got almost all the questions correct on a quiz. The panel said Mrs Z did go up and down, where there were moments, she did engage and participate on her own terms. It said the evidence showed Mrs Z was able to do things or not do things according to her own terms.
57. The IRP concluded the assessed level of need for this domain matched the moderate descriptor as Mrs Z’s mood disturbances, hallucinations, or anxiety symptoms, or periods of distress, which do not readily respond to prompts, distraction, and/or reassurance and having an increasing impact on her health and/or wellbeing.
58. We think the IRP followed the National Framework when it considered Mrs Z psychological and emotional needs. To support this, we can see examples in Mrs Z’s care records to reflect the IRP’s view.
59. On 15 July 2023, the care home recorded ‘[Mrs Z] was in the lounge watching television with other residents’, and on 17 July, the notes state ‘[Mrs Z] was sitting with me in the lounge, we had a nice chat, then I offered a hand massage or nail polish. She got a bit upset…’.
60. We can also see occasions where Mrs Z enjoyed taking part in one-to-one music therapy. For example, on 18 July and 20 July, the care home notes state ‘[Mrs Z] sat happily, relaxed in the dining room’, and ‘singing along to a variety of songs with me…’.
61. In contrast, there were occasions where Mrs Z appeared to be withdrawn from activities and did not want to participate. An example is noted on 23 July where the care staff ‘tried to encourage her to get up but she did not want to’.
62. There are numerous instances in the care records where we can see how Mrs Z’s mood fluctuated throughout the day. For example, Mrs Z was clear on frequent occasions, when staff attended to check on her and switch the alarm off, she did not want people in her room. She would shout and swear and tell them to get out of her room. There is evidence to show Mrs Z did not appear to find the company other others beneficial at times. We also can see she would join in with some activities in the home at times.
63. The above coincides both with what Mr Z and the IRP has said.
64. Mrs Z’s nutritional status as noted within the IRP report does show Mrs Z experienced weight loss, and the discussion also considered Mrs Z did not like others observing her when she was eating and she did not like interacting with others at that time. The IRP also acknowledged the ICB identified Mrs Z often slept for periods during the day and would miss meals, rather than actively refusing or declining meals due to her psychological or emotional state.
65. Our adviser states the DST descriptor specifically asks a person is withdrawn due to a psychological and emotional disorder, which Mrs Z did not have a diagnosis of. Our adviser also explains Mrs Z is described by her family as a strong and determined person, which was acknowledged by the IRP. Mrs Z appeared quite adamant when she did not want to do something, or when she did.
66. Our adviser also goes on to state the evidence within the IRP supports Mrs Z appeared to more irritated and annoyed with carers trying to assist her, rather than emotionally or psychologically impacted. Our adviser says she did appear to respond better to being left to settle or at times reassurance from her children.
67. The records within the evidence do not show Mrs Z was experiencing mood disturbance, hallucinations or anxiety symptoms, or periods of distress which were having a severe impact on her health and/or wellbeing as per a high level of need in this domain. We can see the IRP acknowledged Mrs Z experienced hallucinations, mainly at night and she did experience a disturbed sleep pattern. The panel acknowledged Mrs Z experienced periods of distress and agitation.
68. Our adviser states the evidence from Mr Z and the contemporaneous records considered by the IRP acknowledges Mrs Z was impacted by her psychological and emotional state, and she had variable responses to reassurance, was not always easily distracted and this was impactful on other domains of care. As such, a moderate level of need was determined by the IRP.
69. Having viewed the records, and input from our adviser, we consider the IRP acted in line with the National Framework when it considered Mrs Z’s needs in this domain. We acknowledge Mr Z feels his mother’s needs were high, but the evidence suggests this domain was weighted appropriately according to the moderate descriptor for psychological and emotional needs. We have seen no indication of failings in how the IRP considered this domain.
Drug therapies and medication: symptom control
70. Mr Z feels Mrs Z should have been given a weighting of high in this domain. Both the ICB and the IRP weighted Mrs Z’s needs in this domain as moderate.
71. Moderate needs in this domain are described as:
‘Requires the administration of medication (by a registered nurse, carer or care worker) due to: non-compliance, or type of medication (for example insulin), or route of medication (for example PEG).
OR Moderate pain which follows a predictable pattern; or other symptoms which are having a moderate effect on other domains or on the provision of care.’
72. The DST describes high needs in this domain as:
‘Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for the task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such monitoring the condition is usually nonproblematic to manage.
OR Moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care.’
73. The family told the panel Mrs Z had an anticoagulant care plan which staff had to follow, and this was implemented at the time of the DST. The family explained the staff had to monitor Mrs Z for signs for bleeding especially after she had a fall. The care home also had an anti-hospital avoidance care plan as the hospital was not an ideal place for Mrs Z with her challenging behaviour. Paramedics were called to the home if Mrs Z had a fall, and if an individual was on anticoagulants, they would have to be admitted to hospital.
74. The family’s opinion was the assessed level of need for this domain should be high as the GP reviewed Mrs Z’s medication weekly. There would have been a plan in place for the monitoring of the medication which included monitoring Mrs Z’s urine for signs of bleeding.
75. The ICB representative informed the IRP the anticoagulants were part of a care plan which had been put in place and identified the monitoring for this medication. It said it was not anything outside what the GP would do to ensure whatever was prescribed was accurate and the care staff would have the oversight of a registered nurse within the care home.
76. The ICB confirmed all medications were given regularly and Mrs Z was administered paracetamol (as needed) when she was able to say she was in pain. The staff were able to give medications, and no medications required skilled care which would fall outside what the care home could provide.
77. The panel questioned why zopiclone (treats sleeping problems) was prescribed, and the family confirmed Mrs Z had an unusual sleeping pattern.
78. The panel referred to the evidence which showed zopiclone was not prescribed again.
79. The panel found the weighting of moderate for this domain appropriate, as Mrs Z required her medication to be administered by a registered nurse or care worker due to non-compliance or type of medication.
80. The records confirm Mrs Z’s medications were prescribed doses once daily, except zoledronic acid (used to treat high calcium levels or bone problems), and paracetamol which was given when required. Our adviser says she had a non-complex medication regime.
81. Mrs Z was prescribed edoxaban (medication used to assist blood flow through its anticoagulant properties). Our adviser explains the use of the anticoagulant medication did not require an enhanced level of monitoring, and we can see the panel acknowledged there was a requirement to monitor Mrs Z for signs of bleeding especially after a fall.
82. The records show medications were prescribed by Mrs Z’s GP and administered by care staff within the care home as per the prescription and with routine monitoring of the medications by the registered nurse within the care home.
83. The British National Formulary (BNF) advises patients taking edoxaban, renal (kidney) and hepatic (liver) function should be established prior to treatment and to repeat periodically if treatment duration is longer than one year. Manufacturer advice also advises monitoring for signs of mucosal bleeding and anaemia.
84. Our adviser states this medication does not require routine anticoagulant monitoring via international normalised ratio (INR – a standardised calculation used to assess how quickly your blood clots) as it has a predictable profile, and this means fixed doses can be administered without the requirement for intensive monitoring. BNF notes there is specific clinically indicated situations when assessing edoxaban levels would be required, for example, significant bleeding or suspected overdose, and urgent surgery.
85. The National Framework in Practice Guidance 29 outlines there are not any particular drugs, interventions or conditions which should translate to a particular scoring or outcome when considering eligibility for CHC. This also advises for any given domain; professional judgement should be used to determine the closest fit between what is known about the individual’s needs and the relevant domain level descriptors.
86. We cannot see any evidence to support Mr Z’s view of edoxaban was reviewed weekly by Mrs Z’s GP. The notes show the GP conducted a weekly ‘care home ward’, which did not appear to address the review of Mrs Z’s anticoagulant medication, or any other medications she was prescribed. It was an overview of Mrs Z’s general health and wellbeing.
87. We can see Mrs Z’s medication care plan stated her medications were to be reviewed by her GP on a six-monthly basis and not weekly as suggested by Mr Z. While she did not have a plan for edoxaban, we can see she had a plan for alendronic acid (medication to help bones).
88. We can see the panel also considered the impact of pain on Mrs Z and noted she was able to state she was in pain and paracetamol was given if required.
89. We found the IRP did not identify Mrs Z was prescribed citalopram 10mg once daily. Our adviser comments this would not have altered the weighting within the medication domain.
90. While the evidence suggests Mrs Z was non-complaint with medication, the medication charts do not support doses of medication were missed. We can see Mrs Z required prompting and encouragement, for example and return strategy. This strategy was not directly referred to by the IRP in the medication domain, but noncompliance was acknowledged, and no doses of medication appear to have been missed.
91. The IRP noted Mrs Z required monitoring for bleeding especially after a fall and hospital admission was to be avoided where possible as this was distressing for Mrs Z and could exacerbate her behaviour.
92. We can also see the IRP referred to paramedic protocol saying someone on anticoagulants who fell should be admitted to hospital. Our adviser notes the National Institute of Care and Excellence (NICE) head injury: assessment and early management guidance which refers to asymptomatic patients on anticoagulation or antiplatelet treatment.
93. The guidance states people on anticoagulant medication who have sustained a head injury should be referred to a hospital, and a computed tomography (CT) scan should be considered within eight hours of the injury.
94. The IRP identified this aligned with the moderate descriptor with the drug therapies and medication domain in that Mrs Z required staff in her care home to administer her medications as she was unable to do this herself and was at times not compliant with her medications.
95. The IRP identified this aligned with the moderate descriptor with the drug therapies and medication domain as Mrs Z required staff in her care home to administer her medications as she was unable to do this herself and was at times not compliant with her medications.
96. We have analysed the evidence, and with input from our adviser, we consider the IRP appropriately weighed this domain according to the National Framework. We do not find anything went wrong here.
Did the IRP apply the eligibility tests properly and reach an evidence-based conclusion about them?
97. The IRP also applies an eligibility test to help it make a decision about a person’s CHC eligibility. The National Framework separates this test into four key characteristics: nature, intensity, complexity, and unpredictability. This test is used to establish if the quantity or type of a person’s care needs are more than what the local authority can provide. This indicates they have a primary health need, which in turn indicates they are eligible for CHC.
98. The National Framework sets out questions for the IRP to consider to help establish a person’s level of need. They are outlined in ‘Practice Guidance 3, When identifying a primary health need, how should the four key characteristics be approached?’ (PG3). The National Framework is clear the questions it provides are not meant to be strictly applied and are there to guide the IRP’s considerations. We use these questions when we are looking at whether the IRP properly considered the four key characteristics of Mrs Z’s needs.
99. Below, we will consider the IRP notes, and submissions as Mr Z says he disagrees with the rationale for the four key indicators. We have considered whether the IRP’s decisions and rationale about the four key indicators were clinically accurate. We will consider each key indicator in turn.
Nature
100. The National Framework says this characteristic should ‘describe the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them’.
101. The family challenge the way the IRP considered this characteristic. In their complaint, the family emphasised their mother was 89-year-old with a diagnosis of dementia. Due to her severe cognitive decline, the family said Mrs Z required 24 hours nursing home environment, and when her husband passed away, this had a severe impact on her mental well-being. The family said she was in a constant state of grief. She was prescribed citalopram (treats low mood/depression) medication to take daily.
102. The family said the nature of her illness meant she did not have the processing skills to deal with this situation. She did not want to reside in a care home, and as a result she remained distressed, and withdrawn most of the time. The family also said she was extremely resistant to care interventions and did not like to be monitored.
103. The family said in their complaint, Mrs Z required full assistance from care staff and anticipation to her daily needs. This included monitoring for signs of breathlessness, assistance in eating and drinking, changing her continence pads, providing laxatives, administering her medications, and managing the risks of her anticoagulant medication.
104. In their supporting letter, the family said their mother sustained many serious falls, and injuries. She was admitted to hospital around three times around the time of the DST and suffered from another fall while she was in hospital. The family said the hospital struggled to care for her, and she had one to one care due to her behaviour, and high risk of falls. When Mrs Z was discharged from hospital, the family had a best interest meeting with the care home. It was agreed 15 minutes, and discreet observation was the best option for Mrs Z. This was so they could reduce her escalating behaviour and manage her safety.
105. The family noted their mother could not identify any basic risks to herself, and she was fully reliant on those around her to minimise the risks within her environment. They said her room was very basic with minimum furniture. The family said they believe the nature of their mother’s needs were outside the remit of what the local authority could lawfully provide, and as such she had a primary health need in the nature characteristic.
106. The panel considered the written evidence from both the family and the ICB for the nature characteristic.
107. An overview of Mrs Z’s health conditions was noted. It acknowledged Mrs Z’s breathlessness when she exerted herself and could only walk a few paces before she required rest. She was not prescribed any medication for this, and she was previously diagnosed with chronic obstructive pulmonary disease (COPD).
108. Mrs Z ate minimally as she required support with her meals but did not like being observed. During the review period, she lost more than 10kgs with a malnutrition universal screening tool (MUST – a five-step screening tool used to identify adults who are malnourished or at risk of malnutrition). This indicated her being high risk of malnutrition. She was prescribed complan as a food supplement.
109. The IRP recognised Mrs Z was doubly incontinent and was required to wear pads during night and day. She would been regularly changed, and barrier cream was applied to maximise her skin integrity. She often fell, which caused her bruising, and her waterlow score was 13.
110. The waterlow score is a clinical tool used to assess the risk of developing pressure ulcers, taking into account various patient factors such as mobility, nutrition and skin condition. The risk is graded between below 10 (no obvious risk) to over 20 (very high risk). Mrs Z was therefore at risk of pressure ulcers and had a pressure foam mattress, and pressure cushions for her chair, to reduce this risk.
111. Mrs Z was at very high risk of falls. She was unstable on her feet, would try to stand unaided and this led to having 74 falls within the year. A Zimmer frame was not used often to assist her mobility.
112. While she could communicate with staff and family, it was unreliable, and repetitive. The care staff interpreted Mrs Z’s needs through familiarity. The panel recognised she had short- and long-term memory loss.
113. Despite no formal diagnosis of depression, Mrs Z suffered from anxiety, depression and hallucinations. The care staff tried to reassure Mrs Z with difficulty as she would forget the reassurance and then remember the issue which upset her requiring the care staff to reassure her again. Mrs Z has occasions of lucidity and then would forget, which was a this was a pattern.
114. Mrs Z had dementia and had no insight to her state of mind. There was a Deprivation of Liberty Safeguarding (DoLS) in place, where decisions regarding her health, finance and future care were taken by her family and her needs were anticipated by carers.
115. The panel recognised she had some behaviours which were challenging, and she was not always compliant with care. It referred to the evidence, where incidents identified were managed by the care home. It also acknowledged the staff had a good understanding of Mrs Z’s behaviour and character through familiarity.
116. The IRP acknowledged Mrs Z was not always compliant with her medication, with no doses missed but found her medication routine not complex. It said her GP was regularly in contact with the care home concerning her medications including the anticoagulant medications, which were monitored by the care staff with an oversight from the registered nurse within the care home.
117. It said Mrs Z had a history of possible transient ischaemic attacks (TIA – mini stroke) episodes and these were managed appropriately to ensure her comfort.
118. The IRP found no evidence to indicate support for any other significant needs. The IRP were unable to identify a primary health need for this characteristic.
119. Paragraph 3.3 of the National Framework sets out the following questions to consider when considering this need:
‘Questions that may help to consider this 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?’
120. Based on what we have seen so far, the evidence echoes what was explained by both Mr Z and the IRP. Mrs Z had a vast amount of care needs, which she needed assistance with. On review of the available information, Mrs Z did not need any significant interventions from medical professionals to help care for her.
121. For example, staff were able to follow an overall and consistent pattern in Mrs Z’s eating and drinking habits. We also know they were able to seek well input from the GP over several times to assess Mrs Z’s needs varying over several domains.
122. We can see the IRP identified Mrs Z required all her care provided by carers with the oversight of a registered nurse. The panel acknowledged while Mrs Z did have some challenging behaviours which were at times a barrier to care provision, the care plans in place were usually, but not always, successful.
123. As noted in the drug therapies and medications: symptom control domain, the IRP did not record Mrs Z was prescribed citalopram as highlighted by the family. Our adviser this would not have materially altered the IRP’s conclusion as there are no drugs, interventions or conditions which should always translate into a particular scoring or outcome when considering eligibility for CHC as outlined by the National Framework’s Practice Guidance 29.
124. We can also see the IRP noted Mrs Z diagnoses, particularly dementia as highlighted by her family. The National Framework in paragraph 63 states ‘eligibility for NHS continuing healthcare is a decision to be taken by the relevant ICB, based on an individual assessed needs. The diagnosis of a particular disease or condition is not in itself a determinant of eligibility for NHS continuing healthcare.’ Mrs Z’s diagnosis of dementia would not determine whether she was eligible for CHC.
125. Whilst Mrs Z had many needs, this was being managed effectively and in a timely manner within the limits of what the local authority could provide. There is no evidence to suggest that caring for Mrs Z was problematic, as this was being carried out by professionals who knew Mrs Z, and how to address her needs.
126. Mrs Z’s needs were managed affectively the local authority. Therefore, we have seen no indications of failings in the IRP Chair’s reasoning she did not have an overall high level of need in this key indicator.
127. Our adviser explains the clinical evidence supports the decision made in respect of the nature of Mrs Z’s presentation.
128. We understand how strongly Mr Z feels about his mother’s needs. Considering the evidence there is no indication the nature of Mrs Z’s presentation showed she had a primary health need.
Intensity
129. The National Framework says this characteristic ‘relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’)’.
130. In their supporting letter, the family reiterated their mother was at very high risk of falls and required constant monitoring. She often attempted to mobilise without assistance and frequently removed her sensor mat (a mat that sounds an alarm when stood on), causing staff to intervene repeatedly. To manage her risk, the family said 15-minute observations were used and was regularly kept at the nurses’ station. In the year leading up to the DST, the family noted their mother experienced 74 falls and multiple hospital admissions, with the hospital recommending one-to-one care during waking hours and referred her to the falls team.
131. In their complaint, the family said Mrs Z also suffered from low mood, tearfulness and anxiety, needing frequent reassurance and encouragement. Despite this, she often became distressed for long periods, and the care home contacted the family regularly to help settle her. Meeting her emotional and psychological needs required significant staff time every day.
132. The family highlighted their mother’s behavioural needs by stating Mrs Z frequently displayed challenging behaviour which included shouting, swearing, barricading her door, and removing her sensor mat. This required staff to intervene many times a day. The family emphasised she was extremely disoriented, unable to understand risks, and fully relied on carers for safety and daily needs.
133. Mrs Z often became restless, combative, and difficult to settle, with episodes of distress returning soon after calming. The family said due to constant monitoring needs, repeated falls, and significant behavioural and emotional issues. The family believed she clearly had a primary health need in this key indicator.
134. The IRP agreed Mrs Z’s needs were not severe, and her care interventions were undertaken as often as required. It found she required support and encouragement during mealtimes, with the changing of her continence pads as required, and her skin would be monitored with applications of barrier cream in between changes.
135. The panel said care staff administered medications as per dosage prescribed by her GP, and if required there was oversight from the care home’s nurse. The staff monitored Mrs Z every hour, and this was from a distance as Mrs Z did not like to be observed.
136. The panel considered how long each intervention took, and found at mealtimes, Mrs Z often took 30 minutes to complete due to prompting and encouragement from care staff. It also recognised Mrs Z required encouragement to maintain her fluids so she would not dehydrate and maintain her skin integrity. The panel considered Mrs Z was not compliant with personal care but found no evidence to show this took an excessive amount of time.
137. The IRP also discussed it took one to two carers to meet Mrs Z’s needs, and the care home did not request additional staff to manage her care. It considered the family’s input which was when Mrs Z was in hospital, she required one to one support, but this was not continued in the care home. This was because Mrs Z did not like to be observed. It was agreed patients will have one to one support in a clinical setting, but this is not required in a community setting as it is more of a home environment rather than a hospital setting.
138. The panel agreed her care related to needs over several domains. Her cognitive impairment was a key domain which related to all her needs except for breathing. It said her nutrition was related to cognition as it took prompts and encouragement to eat and took over 30 minutes.
139. It also found her nutrition was related to her skin if she did not drink enough, she was risk at dehydration which could affect her skin integrity. The panel also considered how her skin was linked to continence because if her continence pad was not changed regularly, her skin integrity would suffer, and barrier cream would not be administered which could lead to pressure sores on her sacrum (bottom of the back).
140. The panel found Mrs Z’s mobility was related to cognition as she was unaware of the basic risks of getting up unaided and possible falls which also related to her skin integrity as she bruised easily.
141. It linked her communication to her cognition as Mrs Z could be in a repetitive lucid loop where she understood something one minute and then forgot and forgot if she was upset and therefore required reassurance for the same upset.
142. The IRP agreed Mrs Z’s cognition and psychological and emotional needs related due to her anxiety, repetitive upset and reassurance. It found her behaviour was challenging both verbally and through her behaviour, this was related due to her anxiety and repetitive upset, and reassurance. Mrs Z’s behaviour was challenging both verbally and the IRP said this was related to her cognition as she did not understand the risks. Mrs Z’s medication regime was not complex but related to her cognition and continence.
143. The IRP recognised the family felt Mrs Z’s needs were intense as they watched her change and become a different person. From a clinical perspective, the IRP concluded Mrs Z’s needs were not intense and she did not have a primary health need for this characteristic.
144. Paragraph 3.4 of the National Framework sets out the following questions to consider when considering this need:
Questions that may help to consider this 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?
145. We have reviewed the material evidence and from viewing this, we can see Mrs Z did require a great deal of care and monitoring, but most of her needs were anticipated by her carers. Mrs Z was cared for on a one-on-one basis, and on occasions two carers would be required for assistance.
146. The care Mrs Z needed was routine in its nature for her care staff, and not of a severity that was not manageable. We cannot see any referrals made to any specialist teams.
147. We can see input from her GP on several occasions, for example, on 5 October 2022, the GP attended the care home to administer a flu injection, and on 15 March 2023, we can see the GP did not agree on stopping edoxaban to prevent Mrs Z’s falls due to her increased risk of stroke. The GP gave alternative recommendations to prevent further falls by adding a sensor motion, and to fix the sensor matt in place.
148. Our adviser says the panel discussed one-to-one support and although it was acknowledged this may have been necessary in an acute clinical setting, the care home had not requested any additional staff or support to manage her care.
149. As such, there is no evidence of severe departure from the care plans, or any significant changes to Mrs Z care due to an increasing level of intensity. There was no specialist outside intervention required.
150. We do not consider there to be any indications of failings in the IRP’s decision-making process about the intensity of Mrs Z’s needs. The IRP’s reasoning is supported by the records and in line with the National Framework.
Complexity
151. When the IRP considers the complexity indicator, in line with the National Framework, we would expect it to ‘look at how the needs present and interact with one or more other conditions to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care’.
152. The family said their mother’s daily needs were problematic to meet because they felt there were clear interactions between mobility, cognition, psychological and emotional needs, and behaviour care domains.
153. The family said Mrs Z was at high risk of falls but could not recognise this due to cognitive impairment. They said she repeatedly tried to mobilise without help, removed her bed sensor several times a day, and could not use bed rails safely. As she was on anticoagulant medication, the family said any fall put her at increased risk of bruising and bleeding. She had to be closely monitored, often kept at the nurses’ station.
154. In their supporting statement, the family said Mrs Z’s anxiety, agitation and distress were severe and constant. She struggled emotionally after losing her husband and frequently shouted, swore, resisted care or barricaded herself in her room. Personal care was often refused, and she sometimes ate alone due to distress.
155. The family referred to the support from the care home by stating carers tried various de-escalation techniques, but she rarely settled, and the care home repeatedly contacted the family for assistance.
156. The family emphasised hospital admissions were extremely difficult as hospital staff struggled to manage her behaviour. Medication including mirtazapine (antidepressant) and at the time of the DST, citalopram did not improve her mood and even increased fall risk at times. The family said Mrs Z’s cognition continued to decline, leaving her with complex, intensive needs requiring skilled carers, regular family involvement, and support from multiple healthcare professionals including the GP, falls team and occupational therapist (OT).
157. The family referred to the DoLS report of 2023 which highlighted the various risks and described Mrs Z as having complex needs. The family believes these needs went beyond what the local authority could provide, and Mrs Z had a primary health need in this key indicator.
158. The IRP considered the complexity of Mrs Z’s level of need. The report showed the IRP considered the interaction of various combinations of Mrs Z’s needs. It specifically discussed Mrs Z’s care needs, especially her inability to attend to these independently and said this was a direct result of her cognitive deficits, apart from breathing.
159. The IRP agreed Mrs Z’s needs were not more difficult to address as the care staff were skilled and knowledgeable to care for the residents in the care home, and were familiar with Mrs Z’s needs, and were able to anticipate her needs.
160. It discussed how problematic it was to alleviate Mrs Z’s needs and symptoms. The IRP recognised Mrs Z was uncooperative at times, and it was agreed the care staff undertook the reassure, retreat, return and reassure technique which together with her needs did not make it problematic to alleviate. The panel found no evidence of specialist input, and her GP was in regular contact with the care home staff.
161. The IRP said the care staff were familiar with Mrs Z, who were skilled and knowledgeable in all aspects of her care. It said the staff had oversight of the care home’s nurse if they required further support. It also noted Mrs Z was not compliant with taking her medications and personal care, and her behaviour could be challenging but her response did not make it more difficult for the staff to provide appropriate support.
162. The IRP concluded Mrs Z’s needs were not complex and she did not have a primary health need for this characteristic.
163. Paragraph 3.5 of the National Framework sets out the following questions to consider when considering this need:
‘Questions that may help to consider this include:
• 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?
164. From viewing the available information, it is apparent there are many interactions between several of the care domains, which did impact on Mrs Z’s day to day living. For example, due to her cognition, she needed assistance from her carers with her nutritional and continence needs. As her care records note, ‘due to cognitive impairment, she often forgot to call for assistance when mobilising’, and as such she also required assistance from carers with her mobility.
165. While we can see there were interactions between the domains, influenced by her underlying conditions, Mrs Z’s care could be delivered by carers with input from registered nurse and the GP.
166. There was no evidence to support her care was difficult and complex to manage, nor did she require regular, intensive input from a specialist team.
167. Our adviser commented the IRP considered Mrs Z’s cognitive impairment and the impact this had on other domains of care. Our adviser also says the IRP recognised Mrs Z at times was uncooperative and there were some challenges regarding care delivery at these times.
168. Mrs Z’s care was not complex in nature, and the care records do not indicate that a primary health need was present. The IRP gave the level of detail we would expect when assessing the complexity indicator. Its considerations were in line with the National Framework, and it’s reasoning was supported by the available records and documentation.
Unpredictability
169. As per the National Framework, ‘Unpredictability describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. Someone with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition’.
170. The family raised their concerns about the way this indicator was considered. They said Mrs Z’s mood and behaviour could fluctuate in a very short space of time. Changes in the tone of voice could cause her distress. This fluctuation impacted her provision of care because if she became agitated, Mrs Z would tell the carers to leave. As such, it would make it difficult to engage her in any activity or provide her care. The family recognised various techniques were used to manage her in these situations, and the carers had to use their skill and judgement to know what might be most effective.
171. The family said a lot of time, and skill was used to manage her changeable mood and non-compliance, and their mother’s ability to be reassured during these situations was short lived due to her cognitive impairment.
172. In their supporting statement, the family highlighted Mrs Z’s significant risks due to the fluctuation with her mood and associated behaviour. For example, Mrs Z’s restlessness would lead her to getting up unaided, putting her at a high risk of falls. Mrs Z was described as extremely frail, and due to her agitation, she would try to physically remove the sensor mat.
173. The family said they believed their mother’s mood and behaviour fluctuated every day and this meant she was at risk of falls, injury, and self-neglect if the care she required was not provided in a timely manner.
174. The IRP examined Mrs Z’s needs in the unpredictability indicator and agreed care staff through skill, knowledge, and familiarity were able to anticipate her needs and support her appropriately.
175. The panel said Mrs Z would occasionally wander around during the night, and as such slept in later than mealtimes. The IRP said the care staff would ensure Mrs Z’s nutritional intake would be increased at lunchtime to cover for the lack of breakfast. The IRP said she liked to talk to the care staff in person and would go and sit at the care staff’s station which allowed staff to monitor her.
176. The panel said Mrs Z’s care needs did not change during the review period, but it acknowledged Mrs Z would have the appropriate trajectory decline for a person with dementia. It found her condition as stable and during her times of challenging behaviour, these were within her positive behaviour plan. The IRP noted her care plans were reviewed regularly.
177. The IRP acknowledged throughout the review period; Mrs Z was cared by skilled staff who were familiar with her needs. While Mrs Z had a degenerative illness, it was not rapidly deteriorating. It found the care staff at her care home could manage her care needs.
178. The IRP concluded Mrs Z’s needs were not unpredictable and that she did not have a primary health need for this characteristic.
179. Paragraph 3.6 of the National Framework sets out the following questions to consider when considering this need:
‘Questions that may help to consider this include:
• 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?’
180. Having considered the submissions from Mrs Z’s family and the IRP, we have not seen evidence of fluctuating changes in Mrs Z’s needs, and her care did not have to be drastically amended due to any changes in her needs.
181. While we can see there were interactions between the domains, influenced by her underlying condition, they did not fluctuate unduly daily. We can see Mrs Z’s care plans did not require amendment, and care was not required to change suddenly. Her care followed a natural format which was appropriate to her underlying conditions. There was no evidence to support her care was unpredictable to manage.
182. We recognise Mr Z’s concerns about his mother’s unpredictability especially relating to her fluctuating behaviour, and mood. The records show this was appropriately managed with input from the GP and registered nurses at the care home.
183. For example, on 12 December 2023, the care home records note a doctor came to visit Mrs Z due to hallucinations and increased confusion, and she was prescribed antibiotics for a urinary tract infection (UTI).
184. The IRP’s conclusions can be supported by the evidence we have seen. Our adviser also confirms The IRP did consider Mr Z and the ICB’s supporting information, and within the case file to make its determination Mrs Z did not have a primary health need in relation to the unpredictability indicator. As such, there are no indications of failings in this part of the IRP’s consideration, and it is in line with the National Framework.
185. Given what we have considered above, we do not consider there to be any indications of failings in the IRP’s decision-making process.
Well managed needs
186. In their supporting statement, the family noted the IRP marginalised Mrs Z’s needs because of the high level of care she was receiving within her care home.
187. In terms of her challenging behaviour, the family stated their mother would not comply with personal care, eating and drinking, and with taking medication. It referred to examples of when she would shout at carers and refuse to let them in her room. She also barricaded herself in the room, climbed over bedrails, and removed her sensor mat.
188. Mr Z told the IRP the care home called his family when Mrs Z became distressed on several occasions when she had a fall. He explained even the care home struggled to manage her care in terms of her behaviour, episodes of distress and high numbers of falls. The family referred to the one-to-one support Mrs Z received while in hospital to keep her safe, and in the care home she required 15-minute discreet observations.
189. The family felt the IRP marginalised their mother’s needs because of the level of skill and experience the care staff had. They also felt the report did not reflect the high number of falls and level of risk was reflected in the intensity of her needs because the care home was managing the falls.
190. In their statement, the family said the DST incorrectly stated Mrs Z had four falls in a year, but she had 74 falls documented. It also referred to the IRP which noted she regularly fell, injured herself, and she would refuse to use her Zimmer frame. The family also noted the panel did not mention Mrs Z’s incontinence.
191. The family felt the panel did not fairly assess their mother’s needs and marginalised them for being well-managed within the care home environment. The family disputed it was well managed as they referred to the several occasions when the care home required support from the family, and from health services outside of the home.
192. The IRP said considering all the evidence of Mrs Z’s needs the nature, intensity, complexity, unpredictability of those needs, the IRP concluded that she did not have a primary health need.
193. The National Framework states ‘decision making should not marginalise a need just because it is well managed, well managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, such that active management of this need is reduced or no longer required, will this have a bearing on NHS continuing healthcare eligibility’.
194. Considering the above, our adviser says the IRP clearly acknowledged Mrs Z had care needs, describing those needs and considering the quality and quantity of the interventions which were required to manage them.
195. We can also see the IRP considered Mrs Z’s care and support needs and acknowledged what was required to address those needs. Our adviser says the panel identified there were care and support plans in place to manage her needs. Also, the IRP did not suggest in any of the care domains Mrs Z had no needs, apart from the other significant care needs. The IRP also did not conclude management of any aspect of Mrs Z’s care had been so successful which the requirement for care and support associated with that need was no longer required.
196. Our adviser explains the IRP considered the points raised by Mr Z in relation to challenging behaviour, non-compliance with personal care, fall and other areas by acknowledging plans were in place to manage needs but there were still occasions when those plans had not achieved the expected outcome.
197. Our adviser states the expectation is individuals with certain care and support needs would preferably be placed in an appropriate care environment with staff who have the appropriate knowledge and skill set to address their day-to-day care and support needs. In Mrs Z’s care home held a registration to provide care for individuals living with dementia.
198. We recognise the family have shared they felt the IRP marginalised their mother’s needs, and the IRP did not capture the accuracy of Mrs Z’s falls or the significant level of risk and intensity associated with her needs. We acknowledge how distressing this must have been for the family. The evidence reviewed shows the panel recognised her needs, and the care home was able to provide care for her. We can also see care and support plans were in place to support Mrs Z. As such, we cannot say anything went wrong here.
Procedural concerns
199. Mr Z and his family also raised procedural concerns which include the panel failed to consider the numerous hospital admissions, paramedic call outs and phone calls to the family for additional support. The family said they IRP noted this evidence would be considered in the IRP, but this was not considered.
200. The family emphasised the IRP failed to consider the falls prevention team recommended one-to-one nursing to reduce the risk of falls, distress and hospital admissions. But it was jointly decided between the hospital, care home and family this would cause an increase in Mrs Z’s agitation and behaviours, and as such discreet monitoring was advised.
201. Additionally, references to Mrs Z’s hospital admissions on 1 July 2023, 26 July 2023, and 2 August 2023 were not reflected in the report. The family felt no details were noted in the report regarding the treatment or admissions. The family said this was a key concern because on these three occasions, the care home could not meet Mrs Z’s needs as it was out of their remit.
202. The family also reiterated the IRP failed to consider Mrs Z had 17 paramedic call outs within a year, and there would have been more if a hospital avoidance plan was not in place. They also emphasised their mother was on anticoagulant medication which put her at risk of internal bleeding when she fell, which was often.
203. The family felt the IRP’s failure to consider this evidence had a direct impact on the eligibility outcome as it showed Mrs Z’s needs were above the remit in which the local authority could provide.
204. While the mobility domain notes Mrs Z had four falls within the year, in the IRP’s consideration of procedural concerns, the panel noted the evidence stated she had 74 falls, and the panel confirmed this would be considered in the report. This is reflected in the nature characteristic, where the panel stated ‘[Mrs Z] was at very high risk of falls, was unstable on her feet and would try to stand from her chair or bed which led to her having 74 falls within the year’.
205. The report also noted paramedic attendance had been required, although the panel did not specifically note the number reported by Mr Z. The panel also noted in the drug therapies and medication: symptom control domain, the care home ‘had an anti-hospital avoidance care plan in place because the hospital was not an ideal place for [Mrs Z] …’.
206. In the continence domain, the IRP referenced Mrs Z’s hospital admission on 1 July 2023 for a UTI. It also noted her hospital admission in the mobility domain without a reference to the date, and in the background section of the report on page 7.
207. Our adviser says considering the attendance of paramedics did not then lead to a material change in Mrs Z’s care and support needs.
208. In terms of phone calls to family, we can see the panel noted in the psychological and emotional needs domain, the following ‘…[Mr Z] was called by the carers as [Mrs Z] would not respond to them and would get upset and distress; [Mr Z] tried to calm [Mrs Z] down over the phone or he would visit the home when [Mrs Z] was non-responsive’.
209. We can also see the in the intensity characteristic, the IRP considered the points about Mrs Z requiring one-to-one support in the hospital, but this was not continued in the care home as she did not like to be observed. The report states ‘the IRP agreed that if [Mrs Z] required a one-to-one, both for safety and in the person’s best interest, a 1 to 1 would be requested. It was agreed that patients will have a 1 to 1 in a clinical setting but in the community, they would not need a 1 to 1 because the community setting and a nursing home is more of a home environment than a hospital institution’.
210. In the mobility domain, the IRP referenced the involvement of the falls clinic and highlighted her noncompliance with their advice. It also stated ‘[Mrs Z] did not like 1 to 1 support and the care minute observations which had to be undertaken discreetly.’
211. As we have already considered in our analysis, the IRP report referenced in the drug therapies and medication: symptom control domain about Mr Z’s concerns his mother was on anticoagulant medication. We have identified this did not require specific monitoring except for when Mrs Z had a fall, which would require further medical input to assess any bleeding.
212. We recognise Mr Z has told us the care home were not able to meet Mrs Z’s needs as it was outside of their remit, while Mrs Z was receiving medical treatment in hospital. Mr Z’s submission also states it is important to consider the paramedic call outs as they evidence clear medical needs which the local authority again was not under a duty to provide.
213. Our adviser explains hospital admissions and paramedic callouts are not direct determinants used anywhere within the National Framework in relation to eligibility for NHS CHC. They are also not applicable as to whether someone has needs above the limits of the local authority can provide.
214. Our adviser further explains what could be considered is whether the conditions leading to admissions and paramedic callout directly impacted and materially changed the level care and support an individual requires.
215. In this case, the panel along with the evidence did not identify Mrs Z’s care and support needs changed or altered because of any hospital admission or paramedic callout. We can see the report documented within the unpredictability characteristic Mrs Z’s care needs did not change during the review period, and her condition was stable, acknowledging Mrs Z would have the appropriate trajectory decline for a person with dementia.
216. The IRP identified Mrs Z’s needs at section 10 of the report which considered as a whole, the nursing or other health services required by Mrs Z were not more than incidental or ancillary to the provision of accommodation which the local authority social services are under a duty to provide or were not of a nature beyond which a local authority whose primary responsibility is to provide social services could be expected to provide.
217. In section 14 of the report, we can see the panel considered the comments provided by the family about their procedural concerns, and the report addressed these concerns by providing recommendations in section 16.
218. We would like to reassure the family the IRP carefully considered all the key evidence they provided, including the information submitted within the relevant domains and key characteristics. The panel acknowledged and reflected on the points raised and understands the importance of the family’s perspective.
219. After the thorough consideration of all the available evidence, the panel concluded the evidence presented did not affect the overall decision reached. We can see the decision was made collectively and in line with the National Framework, while recognising and respecting the family’s concerns.
220. We understand how important this complaint is for Mr Z and his family. We also recognise this decision will be disappointing for Mr Z. We hope our consideration of his complaint reassures him that we have taken his complaint seriously and have undertaken a thorough consideration of the issues.