1. We uphold the complaint about Herefordshire and Worcestershire Integrated Care Board (the ICB). He have found it made mistakes in how it handled Mrs D’s complaint about its continuing healthcare planning. It did not respond to her complaint in a timely manner. The complaint was important to Mrs D as it related to her father’s care before he died. We can see how upsetting and frustrating it was for Mrs D to fight to get the answers to her questions.
2. Since we issued our provisional views, the ICB has taken some action to resolve Mrs D’s complaint. It has now responded to the complaint in writing, and it has acknowledged its mistakes and apologised for the impact they had on her. But we think it should do more to put things right for Mrs D. The ICB has agreed to pay financial compensation. We also recommend it meets with Mrs D to discuss the complaint.
3. Mrs D has not asked us to recommend specific service improvements for the ICB, but we are pleased to read it has proactively put steps in place to prevent situations such as those raised in this complaint from happening again. After reading the response, Mrs D has asked to see evidence of the improvements the ICB has made. We recommend the ICB does this too.
The complaint
4. Mrs D complains the ICB has not investigated or responded to her complaint about the care it funded for her father, Mr S.
5. Mrs D says the ICB left her feeling distressed and frustrated. She has not been able to grieve her father’s death properly and feels like she has let him down, as she has not been able to resolve this issue for him.
6. Mrs D wants the ICB to investigate and fully respond to her complaint. She also wants it to acknowledge the mistakes it has made in its complaint handling, and apologise and pay compensation for the impact they had on her.
Background
7. Mr S was discharged from hospital in early September 2023. He was cared for at home, funded by fast-track continuing healthcare.
8. Mr S was mostly cared for from his bed. He was able to sit in his chair for short periods of time and this was something he enjoyed. Mrs D asked his care provider and the ICB if they could change her father’s care package to allow for the time needed to hoist him from his bed to his chair, and then return him to his bed at the end of their shift. The ICB told Mrs D it could not make this change.
9. Mr S sadly died in late December 2023.
10. On 23 April 2024, Mrs D complained to the ICB about its care planning decision. The ICB did not respond to Mrs D’s complaint until 6 February 2026, after we shared our provisional views report.
Evidence we are considering
11. To understand what happened we have considered the following information when coming to our decision:
• Mrs D’s complaint and supporting information
12. We use relevant law, policy, guidance and standards to inform our thinking. This allows us to consider what should have happened. In this case, we have referred to:
• the NHS Complaint Standards (2022) • the Local Authority Social Services and National Health Service Complaints (England) Regulations (2009) • our Principles of Good Administration (2009).
Findings
13. Mrs D complained the ICB had not responded to the complaint she made about how it planned her father’s care. We are not looking at the ICB’s care planning itself. The ICB did tell us it had completed its investigation and the response was being prepared for sharing with Mrs D. But despite multiple interventions from us, it had not sent it and did not until after we had issued our provisional views, which is why we have investigated its complaint handling.
14. The ICB’s investigation took a significant amount of time and Mrs D has told us not getting the answers she has asked for made her feel like she had let her father down, and prevented her from grieving his death.
15. Mrs D complained to the ICB about its care planning on 23 April 2024. It did not provide a response and she contacted us in January 2025 to ask if we could intervene.
16. We sent two letters, and several emails to the ICB to ask it to update Mrs D and us on its work on her complaint. The ICB advised it would respond to the complaint by the end of March 2025. It did not do this.
17. Between July and September 2025, we asked the ICB for updates on its investigation. It advised senior managers at the ICB were reviewing the casefile, and could not provide any further information on when it would be sharing the outcome of its investigation.
18. In September, we explained to the ICB we were considering carrying out a detailed investigation of Mrs D’s complaint. We suggested it could consider the NHS Complaint Standards to put things right for her, and advised Mrs D was looking to meet with the ICB to discuss her concerns about its care planning. The ICB did not act on the information we provided and we confirmed our detailed investigation.
19. The ICB responded to Mrs D’s complaint on 6 February 2026, more than a year and nine months after she made her complaint. The NHS Complaint Regulations provide a guideline of six months for the ICB to respond to a complaint. This is not prescriptive, it allows for some investigations to take longer than six months and in those circumstances, it says organisations should write to the complainant to explain why the investigation is not complete, and sent the response as soon as possible.
20. To add to this, our Principles of Good Administration say, ‘public bodies should behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits. They should tell people if things take longer than the public body has stated, or than people can reasonably expect them to take.’
21. The ICB did not act in the spirit of the NHS Complaint Regulations, or followed our Principles. The investigation took well over a year longer than the six months set out in the Regulations, with no meaningful updates to Mrs D. We have found it did not deal with Mrs D helpfully or promptly and it has not provided any reasoning for such a significant delay.
22. As described above, we have signposted the ICB to the NHS Complaint Standards in an attempt to resolve this complaint for Mrs D as soon as possible. The Standards say, ‘staff look for ways they can resolve complaints at the earliest opportunity.’ We explained to the ICB what Mrs D was hoping to achieve. We cannot see it has put any consideration into the information we provided. It did not have any regard for the NHS Complaint Standards here.
23. We have found the ICB should have done things differently here. It should have completed its investigation and shared its response with Mrs D much sooner than it did. If there was a good reason why it could not do this, it should have focussed on Mrs D as its customer, and explained why it could not complete the investigation. It should have also clearly set out when it would realistically complete the investigation.
24. We have found substantial failings in how the ICB has managed Mrs D’s complaint. These failings have had a negative impact on her and we explain our current thinking on this next.
The impact the ICB’s failings had on Mrs D
25. Mrs D has told us the ICB’s failure to respond to her complaint has distressed her. She wanted an outcome to this matter in her father’s memory and she feels like she has been unable to fully grieve his death whilst the complaint remained unresolved.
26. Mrs D has dedicated a lot of time to this issue. She represented her father’s wishes whilst he was alive to try and change the care plan. She has continued to act in his best interests after he sadly died by sending her complaint to the ICB with a view to getting its rationale on not amending her father’s care. The ICB took far too long to provide this, and Mrs D was left not knowing if things could have been different for her father during the last months of his life.
27. We can appreciate the distress Mrs D has felt. She brought this complaint to us explaining she feels like she has let her father down by not being able to bring this to a conclusion. We understand why she feels this way. The ICB has directly contributed to Mrs D feeling this way by taking so long to respond to her complaint.
28. We are not taking a view on whether the ICB should have amended Mr S’s care plan. But not knowing the ICB’s view or reasoning on this has added to what was already a very difficult time for Mrs D. We understand why she feels she has let her father down and the ICB should take steps to put this right for Mrs D.
What the ICB has already done in response to this complaint
29. We are pleased to hear the ICB has taken steps to resolve this complaint for Mrs D since we shared our provisional views. It has responded to the complaint and sent a letter acknowledging where it should have done better and sincerely apologising for the impact on Mrs D. It has also set out where it has made improvements to its complaints service.
30. As it has already done these things, we do not need to ask it to do this again now and Mrs D has agreed with this. But there are more steps it should take to resolve this complaint for Mrs D. We have made recommendations for what the ICB should do, which is what we outline next.
Our recommendations
31. Mrs D has told us she wants the ICB to meet with her to discuss its complaint response and to provide more information on the service improvements it set out. She would also like financial compensation which the ICB has confirmed it will pay. As it has not completed these things yet, we are still making these recommendations.
32. We have referred to the NHS Complaint Standards. These state that NHS organisations should be open and honest when things have gone wrong, recognise when this has had an impact on people, and identify suitable ways to put things right. The ICB’s Complaints Handling Policy sets out that it can meet with complainants in person to discuss the outcome of the investigation and the actions it intends to take.
33. The Standards also say organisations should make sure people are kept involved and updated on how the organisation is taking forward all learning or improvements relevant to their complaint.
34. Based on this, the ICB should take steps to fully resolve this complaint for Mrs D. Its mistakes have had an impact on her, which it should put right.
Recommendation 1
35. Within one month of the date of this report, the ICB should arrange to meet with Mrs D to discuss its complaint investigation and response. During the meeting, it should show Mrs D how it has made improvements to its complaints service, as set out in the complaint response.
Recommendation 2
36. We can make recommendations for financial compensation where we have identified a failing which has caused an injustice or hardship.
37. To determine a level of financial remedy, we have looked at ‘Our guidance on financial remedy’ which includes a severity of injustice scale. It guides us on how much remedy we should recommend, making sure our recommendations are consistent across the complaints we handle, and transparent for everyone who uses our service.
38. Following this review, there has been complaint handling failings that have lasted more than a year and nine months, which has resulted in ongoing distress to Mrs D. Based on this, we recommend that within one month of the date of this report, the ICB pays Mrs D £1200 in recognition of the distress she has felt since she made her complaint in April 2024.
39. The ICB should write to us to confirm it has completed our recommendations.