Summary: Ms Y complains the Council, Care Provider and ICB failed to assess her mother for NHS Continuing Healthcare. We will not investigate the complaint because we cannot achieve the outcome Ms Y wants and parts of the complaint are premature.

The complaint

1. Ms Y complains:
1. London Borough of Islington, the “Council”, failed to properly complete an NHS Continuing Healthcare (CHC) checklist and involve family members in a care assessment for her late mother, Mrs X;
2. North Central London Integrated Care Board, the “ICB”, failed to properly assess Mrs X for CHC; and,
3. BUPA UK, the “Care Provider”, failed to alert the relevant bodies about a worsening in Mrs X’s health which delayed CHC.
2. Ms Y says had the different bodies taken proper action at the relevant times Mrs X would have received CHC before she died.

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The Ombudsmen’s role and powers

3. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
4. We will not generally investigate a complaint unless we are satisfied the matter has been brought to the relevant organisation’s attention and that organisation has had a reasonable opportunity to investigate and reply to the complaint. (Local Government Act 1974 section 26(5), as amended and Health Service Commissioners Act 1993, section 9(5))
5. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
6. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• the injustice is not significant enough to justify our involvement, or
• we cannot achieve the outcome someone wants, or
• it would be reasonable for the person to ask for a review or appeal.
  (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

7. I considered evidence provided by Ms Y, the ICB, Council and Care Provider; as well as relevant law, policy and guidance.

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What I found

8. CHC is care arranged and funded by the NHS. The first step is for a health or social care professional to complete a CHC checklist. The threshold for meeting the CHC checklist is low.
9. A negative checklist means the person is ineligible for a full assessment and CHC. The person can ask the ICB to reconsider this decision and if they remain unhappy they can complain to the ICB. There is no further right of appeal. A positive checklist means the person needs a full multidisciplinary assessment of eligibility for CHC.
10. A person can make a claim for CHC on behalf of a person who has died. The Department of Health published guidance in December 2023 which includes the process and timescales for making such claims.

Background to the complaint

11. Mrs X was a resident at Stamford Care Home, the “Care Home”; owned and managed by BUPA UK. Mrs X had complex health needs. In October 2022 Ms Y says she asked the Council for CHC; however it was not until Ms Y involved her MP in June 2023 that the assessment process started.
12. On 19 June the Care Home completed a CHC checklist with a Council staff member. Ms Y says her daughter was present and understood the outcome was that Mrs X should have a full CHC assessment.
13. In October 2023 the ICB completed a CHC checklist with input from Ms Y and a manager from the Care Home. Mrs X did not meet the criteria for a full CHC assessment. Ms Y says she never received a copy of this assessment.
14. Mrs X’s health worsened and the Care Home made a referral for CHC funding on 24 March 2024. Mrs X died the following day. Ms Y says the Care Home should have made an earlier referral and its failure resulted in Mrs X missing out on CHC funding.
15. In response to Ms Y’s complaint, the ICB said the October 2023 checklist aligned with evidence provided during the assessment. Following both an internal audit and review, the ICB found nothing it considered untoward or which would change the checklist outcome.
16. The ICB accepted and apologised for its failure to communicate its October 2023 decision. It said it would refer Mrs X’s case to start its CHC Appeals Process.
17. The Care Provider’s complaint response apologised for delays in making a referral for CHC when Mrs X’s health worsened in March 2024, and its communication about Mrs X’s eligibility for CHC. It also offered to support Ms Y in a retrospective CHC request.
18. Ms Y complained to the Council in January 2024 about inaccurate charging, the failure and delay in completing a checklist, and issues related to care and social workers failing to include Ms Y and Mrs X in decision making. The Council could not evidence it had involved family during a care assessment or escalated requests for CHC assessments. The Council’s complaint response accepted and apologised for its poor recording. It also said it would remind staff about the importance of keeping complete and accurate records.

Why we will not investigate

19. In making decisions about why we will not investigate matters we must consider the public purse and the laws which govern what we can investigate. The substantive element of Ms Y’s complaint is the lack of CHC for Mrs X. The ICB is responsible for making decisions on CHC and retrospective funding. This includes an appeal route. The ICB should have the opportunity to complete this process before the Ombudsmen can consider this. Once the appeal process has been completed, Ms Y can ask PHSO to consider this part of the complaint.
20. The ICB has accepted fault in failing to tell Ms Y the outcome of the October 2023 checklist was negative. Because of this failure Mrs X lost an opportunity to complain about this decision. However, I do not consider this caused Mrs X significant unremedied injustice as the ICB completed a review of the checklist and the outcome remained unchanged. It also apologised for the error and is considering Mrs X’s case through its appeals process.
21. The Council and Care Provider have apologised for failings related to delays in completing and communicating decisions about the CHC checklist and other matters. It is therefore unlikely an investigation would achieve any further outcome.

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Decision

22. We will not investigate this complaint as we cannot achieve the outcome Ms Y wants, there is no unremedied significant injustice, and part of her complaint has not yet been considered by the ICB.

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Investigator's decision on behalf of the Ombudsman