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Home > Publications > Selected Cases > Selected Investigations Completed AprilSeptember 2003 > Case No. E.112/02-03
Complaint against the former Gloucestershire Health Authority
Summary of Case
In November 1999, Mrs M’s mother, Mrs D was admitted to hospital following a stroke, and remained there until June 2000, when she was discharged to a nursing home. Mrs D, who had insulin dependent diabetes, and had been left immobile and unable to speak by the stroke. Prior to her discharge, the PEG a tube which had been in place for feeding was removed. The Health Authority agreed to pay 10% towards her continuing care costs. In February 2001 the family asked for a review of their mother’s eligibility for NHS funding. Following an assessment completed in April 2001, the Health Authority advised the family that Mrs D did not meet their eligibility criteria for full funding, and that the 10% had been paid in error, as the PEG had been removed. The family appealed against the decision, on the grounds that Mrs D’s primary need was for nursing care, in line with the precedent set in a Court of Appeal hearing in 1999 (the Coughlan judgment). A review of procedures was carried out by the Health Authority in November 2001, however the decision was again made that Mrs D did not qualify for NHS funded care. Mrs D died in December 2001. Mrs M complained to the Ombudsman.
Findings
The matter investigated was that inadequate consideration was given to Mrs D’s eligibility for NHS funded continuing care, particularly in regard to her nursing needs. The Ombudsman found the Health Authority’s process in assessing Mrs D’s healthcare needs was flawed. The Ombudsman’s assessors found that the assessment documentation was incomplete, and the family were given no information about the eligibility criteria, nor were they properly involved in the discharge process, when decisions needed to be made about Mrs D’s future nursing care. There was no evidence that the nursing home received a proper care plan for Mrs D. Whilst the Health Authority’s eligibility criteria had been reviewed in the light of the Coughlan judgment, the documentation supporting assessment had not been reviewed, which led to inconsistency and lack of clarity. The Health Authority were criticised for the length of time taken to complete their review following the family’s appeal in April 2001. The Ombudsman upheld the complaint.
Remedy
From 1 April 2002, the Health Authority was abolished and responsibility for funding continuing healthcare was transferred to a new body, West Gloucestershire Primary Care Trust; responsibility for setting eligibility criteria moved to Avon, Gloucestershire and Wiltshire Strategic Health. The Ombudsman recommended that, in liaison with other relevant bodies, the SHA should devise a robust process with comprehensive guidelines to ensure that proper and timely assessment is carried out of patients who may be entitled to continuing healthcare funding. This should include the involvement of families and carers, and participating staff should be fully trained to carry out effectively the assessment process. The Ombudsman also recommended that the SHA, in consultation with the PCT, should review its eligibility criteria and should then determine whether Mrs D and any other patients assessed under the procedures in place at the time, were wrongly refused funding for continuing care, and if that is found to be the case, arrangements should be made for reimbursing the costs. The SHA agreed to these recommendations and apologised to Mrs M for the shortcomings identified.
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