The Ombudsman's final decision
Summary: We will not investigate this complaint about an alleged failure by the Council to refer the complainant’s late mother-in-law for an NHS Continuing Health Care assessment. This is because an assessment referral was already scheduled and there is insufficient evidence of fault by the Council for not making an earlier referral.
The complaint
The complainant (Mr X) complains about Council care charges in respect of his late mother (Mrs W) who died while in residential care. He says the Council has billed approximately £725 for care charges covering a three-week period up to the date when Mrs W died. Mr X says Mrs W was receiving end-of-life care during this period which he believes would make her eligible for NHS Continuing Health Care (CHC). He also refers to Mrs W suffering a fall and injury in July 2023 which would also have affected her eligibility for CHC funding. Mr X alleges the Council is at fault for not seeking CHC funding sooner and he disputes the invoiced amount as not being chargeable.
In summary, Mr X says the alleged fault has denied Mrs W of CHC funded care which means she would not have needed to pay the Council’s weekly care contribution. He says dealing with the Council in respect of these issues has caused him excessive time and trouble. As a desired outcome, Mr X wants the Council to make a retrospective request for CHC funding. He also wants it to be held accountable for the alleged failings.
The Ombudsman’s role and powers
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 there is not enough evidence of fault to justify this. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
How I considered this complaint
I considered information provided by the complainant and the Council. I also considered the Ombudsman’s Assessment Code.
My assessment
Importantly, the claimed injustice, at this stage, is speculative. This is because we cannot say with any certainty that Mrs W would have been eligible for CHC funding had there been an earlier assessment. I could only identify an injustice were I to identify fault by the Council for not referring Mrs W for a CHC assessment sooner. It should be noted however that a request can be made to the NHS for retrospective CHC funding.
The Council has confirmed that the fact Mrs W was receiving end of life care does not mean she would have been eligible for CHC funding. This is because CHC does not fully fund end of life care. The Council has explained it also did not receive confirmation from Mrs W’s doctor that she was receiving this type of care. In any event, Mrs W was scheduled to be referred a CHC assessment in October 2023. For these reasons, there is insufficient evidence of fault by the Council for not requesting an earlier CHC assessment.
The Council referred Mrs W for a CHC assessment in October 2022 which confirmed she was not eligible for this. A further review was then scheduled for October 2023. Following the fall in July 2023, the care home made a safeguarding referral to the Council which was assessed. The assessment did not identify any changes to Mrs W’s needs and so it did not consider an early CHC review was necessary. In my view, the Council properly kept Mrs W’s needs under review, including scheduling appropriate times to make referrals for CHC funding. There is insufficient evidence of fault with respect to it not making a CHC referral in response to Mrs W’s fall.
Final decision
We will not investigate this complaint. This is because there is insufficient evidence of fault by the Council for not making an early CHC funding referral.
Investigator's decision on behalf of the Ombudsman