Summary: We will not investigate this complaint about the Council’s actions during the assessment for NHS funding for adult care. The Council’s actions do not cause the claimed injustice of a failure to award Continuing Healthcare funding. That is an NHS decision, and is not an outcome the Council nor the Ombudsman can achieve.

The complaint

1. Mr B says the Council failed to fulfil its duties in performing a Continuing Healthcare (CHC) assessment for Mr C. Mr B says the Council failed to understand his complaint and sent the complaint response to the wrong person creating a data breach. Mr C lives in a care home which Mr B believes should be funded by CHC.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide:

• any fault has not caused significant enough injustice to the person who complained to justify our involvement, or
• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint, or
• there is no worthwhile outcome achievable by our investigation.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

3. I considered information provided by the complainant.
4. I considered the Ombudsman’s Assessment Code.
5. I considered the National framework for NHS continuing healthcare and NHS-funded nursing care.

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My assessment

6. NHS continuing healthcare (CHC) is a package of health and social care that is arranged and funded solely by the NHS where an individual is found to have a primary health need. 
7. The Council completed a Checklist which showed Mr C may be eligible for CHC. The NHS then led a multidisciplinary team meeting (MDT) to decide whether Mr C was eligible for CHC funding. The NHS decided Mr C was not eligible for CHC funding.
8. The NHS was responsible for the MDT meeting and the decision making, so any concerns about that process are for the NHS and are not within our powers to investigate.
9. We cannot say had the Council acted differently the NHS would have made a different decision. The claimed injustice is ultimately caused by an NHS decision. The outcome Mr B wants which is for Mr C to receive CHC funding, is not an outcome the Council nor the Ombudsman can achieve.
10. We do not investigate all complaints we receive. In deciding whether to investigate we need to consider various tests. These include the alleged injustice to the person complaining. We only investigate the most serious complaints.
11. There is no worthwhile outcome to achieve in investigating the Council’s actions earlier in the process. Even if there was any fault, it does not cause a significant enough injustice to justify an investigation and does not cause the claimed injustice of not receiving CHC.
12. Mr B can appeal the NHS decision about Mr C’s eligibility for NHS CHC funding.
13. Mr B is also unhappy with the way the Council dealt with his complaint. But it is not a good use of public resources to look at the Council’s complaints handling if we are not going to look at the substantive issue complained about. We will not therefore investigate this issue separately.
14. The Information Commissioner’s Office is better placed to consider concerns about a breach of personal data.

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Final decision

15. We will not investigate Mr B’s complaint because there is not a significant enough injustice caused by the Council’s actions to justify an Ombudsman investigation. The outcome Mr B wants to achieve is for Mr C to receive CHC funding; this is a decision for the NHS and is outside the remit of the Ombudsman and the Council. Mr B also wants the Council to improve its process. The Council’s complaint response identifies learning from the complaint. I am not satisfied the case justifies investigation for the reasons given in this statement, or that we would add to the Council’s response or achieve anything further.

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Investigator's decision on behalf of the Ombudsman