Complaint about Rotherham Primary Care Trust and South Yorkshire Strategic Health Authority (now Yorkshire and the Humber Strategic Health Authority)
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Flawed consideration of an application for retrospective continuing care funding
Background to the complaint
Mrs J was admitted to a nursing home on 10 November 1999 following a fall in September 1999 in which she fractured her hip. She also suffered from dementia and transient cerebral ischaemia (temporary neurological problems caused by interrupted blood flow). She was transferred to a second nursing home in November 2003 and remained there until she died on 5 September 2004.
Mrs J’s friend, Mrs C, applied for NHS continuing healthcare funding on Mrs J’s behalf in April 2003. The Local Review Panel of Rotherham Primary Care Trust (the Trust) considered Mrs C’s claim. It concluded that Mrs J was not eligible for continuing care funding from 10 November 1999 to 3 August 2004, but from 4 August 2004 her condition ‘became more unstable and complex’ and she was thus eligible for funding from that date until her death. Mrs C appealed to South Yorkshire Strategic Health Authority (the Authority) about the decision. The Continuing Care Appeal Panel, held on 22 November 2004, upheld the decision of the Local Review Panel.
In January 2005 Mrs C complained to the Ombudsman about the Authority’s decision. We investigated and recommended that the Authority thoroughly review Mrs J’s case. The Trust subsequently completed a portrayal of Mrs J’s healthcare needs and a second Local Review Panel was convened to reconsider Mrs C’s claim. The Panel concluded that Mrs J did not meet the eligibility criteria for continuing care funding before 4 August 2004.
What we investigated
In May 2007 Mrs C complained again to the Ombudsman that Mrs J had not been assessed for continuing care funding at any time she was resident in the nursing homes. She said that the Trust had not compiled a robust and accurate portrayal of Mrs J’s healthcare needs and, in particular, that the summary of needs had given insufficient attention to the end stage gangrene from which Mrs J suffered, and which required the involvement of a tissue viability nurse.
We considered whether the Trust’s review process met the following expectations set out in the Principles of Good Administration:
- ‘Getting it right’ (acting in accordance with the public body’s policy and guidance – published or internal).
- ‘Being open and accountable’ (being open and clear about policies and procedures and ensuring that information, and any advice provided, is clear, accurate and complete; and stating criteria for decision making and giving reasons for decisions).
- ‘Acting fairly and proportionately’ (ensuring that decisions and actions are proportionate, appropriate and fair).
In the context of retrospective continuing care complaints this is taken to mean that there will have been:
- a robust portrayal of health needs, drawn from all the available and relevant evidence;
- a fair, proportionate and reasonable process of assessment/review which is inclusive of relatives and carers;
- consideration of the person’s individual healthcare needs by an appropriately constituted and qualified panel, and comparison of these healthcare needs to the eligibility criteria; and
- a decision conveyed to the claimant that clearly explains how it was reached, the evidence used and the rationale.
We examined all the relevant documentation. We also took advice from an experienced nurse with considerable experience of continuing care reviews and assessments.
What our investigation found
We found that the needs portrayal did not provide evidence of Mrs J’s healthcare needs between 2000 and 2002, and significant events recorded in the portrayal concerning tissue viability and nutrition from 31 March 2004 were not reflected in the summary and did not appear to have been considered by the Panel. There was no reference in the Panel report to any of the contemporaneous records to support the statement that Mrs J was not eligible for funding before 4 August 2004. We found that Mrs C had not been given a clear explanation for how the decision was reached, the evidence used and the rationale for the decision.
In summary, the Trust’s review process was flawed and for that reason we upheld Mrs C’s complaint. The investigation was concluded in May 2008.
Outcome
As a result of our recommendations:
- the Trust agreed to apologise to Mrs C for not having thoroughly reviewed Mrs J’s case; and
- Yorkshire and the Humber Strategic Health Authority (as the Authority’s successor) agreed to ensure that a robust re-review of Mrs J’s case would be undertaken.
Principles of Good Administration
The following Principles of Good Administration were referred to in this case summary:
- ‘Getting it right’ (acting in accordance with the public body’s policy and guidance – published or internal).
- ‘Being open and accountable’ (being open and clear about policies and procedures and ensuring that information, and any advice provided, is clear, accurate and complete; and stating criteria for decision making and giving reasons for decisions).
- ‘Acting fairly and proportionately’ (ensuring that decisions and actions are proportionate, appropriate and fair).
