NHS South West London Clinical Commissioning Group

3. Mr and Mrs B complain that between April and August 2019 the CCG failed to arrange appropriate care for Mrs F. They also complain the CCG did not provide an adequate response to their complaints about Mrs F’s care. Their specific concerns are set out in detail later in this statement.

6. Before we decide if we should investigate a complaint, we look at whether there is an organisation that is better placed to deal with the concerns. In this case, we have considered whether the SAB is better suited to giving an answer to Mr and Mrs B, and whether it can provide the outcomes they are seeking.

7. We reviewed the scope of Mr and Mrs B’s complaint against the key themes for the SAB review, as set out in paragraph 5. We considered whether the SAB review will address each part of their complaint.

8. In relation to the care arranged for Mrs F between April and August 2019, Mr and Mrs B complain the CCG:

· Delayed providing the necessary paperwork to place Mrs F in a nursing home, that they approved, meaning Mrs F lost her place there. This will be covered by key theme A.

· Placed Mrs F in a nursing home without any consultation with her family. This will be covered by key theme A.

· Placed Mrs F in a nursing home which was not equipped to support service users with ongoing mental health needs and did not carry out any review of her placement to confirm it was safe and appropriate. This will be covered by key theme B.

· Inappropriately refused a request by Mrs F’s GP to fast track her application for continuing healthcare (CHC) funding, and incorrectly told the GP they could not complete the application form as it needed to be completed by nursing home staff. This will be covered by key theme F.

· Made the decision to deny fast track CHC funding without the opinion of anyone medically qualified. This will be covered by key theme F.

· Made the decision to deny Mrs F’s fast track CHC funding application without ever seeing or speaking to her directly. This will be covered by key theme F.

· Refused Mrs F’s fast track CHC funding application even though she was outside the automatically funded 28 day placement period. This will be covered by key theme F.

· Inappropriately insisted Mrs F have an NHS continuing healthcare decision support tool (DST) assessment as a means of circumventing her fast track CHC funding application. This will be covered by key theme F.

· Tried on three occasions to carry out a DST assessment, without notifying Mr and Mrs B, despite knowing they had full legal power of attorney (LPA) and enduring power of attorney (EPA). This will be covered by key theme C.

· Failed to communicate who the CCG’s multidisciplinary team (MDT) coordinator was or provide their contact details prior to Mrs F’s DST assessment on 19 July 2019. This will be covered by key themes A and F.

· Carried out Mrs F’s DST assessment without having full access to her nursing home records. Mr and Mrs B said they were only given Mrs F’s behavioural records at the meeting. This will be covered by key theme A.

· Allowed the DST assessment to proceed even after being made aware that Mrs F’s full nursing home records had not been passed to the MDT by nursing home staff. This will be covered by key theme A.

· Did not take account of their shock and upset at the disclosure of Mrs F’s attempt to take her life during the DST assessment meeting. By not doing this, it acted in an unprofessional and uncaring manner. This is unlikely to be directly covered by the review but there is a chance it will be covered indirectly if the review is critical of the CCG’s actions. We cannot confirm this until the review has been completed.

· That two nurse advisers, who reviewed Mrs F in advance of the DST assessment meeting, raised no safety concerns about the fact staff at the nursing home had removed Mrs F’s staff call bell or that she was in a distressed state when they assessed her. This will be covered by key theme B.

· Ignored Mrs F’s fast track CHC funding application, and supporting letter from her GP, during the DST assessment meeting. This will be covered by key theme F.

· Rushed to complete Mrs F’s DST assessment as quickly as possible. This will be covered by key theme F.

· Ignored their advocates’ request to cover specific topics at the start of the DST assessment meeting, while a nurse from the nursing home was present to address those concerns. This will be covered by key theme F.

· Inappropriately sought to mark DST assessment domains down, meaning they were considered lower risk, as opposed to marking them up as they should have. This will be covered by key themes A and F.

· Forced them to go ahead with the DST assessment meeting despite the disclosure of information about Mrs F’s suicide attempt. This is unlikely to be directly covered by the review but there is a chance it will be covered indirectly if the review is critical of the CCG’s actions. We cannot confirm this until the review has been completed.

· Did not share the DST assessment outcome with them or notify them that the DST assessment was passed to the CCG’s CHC panel following the meeting or communicate the panel’s decision that Mrs F was deemed eligible for CHC. This will be covered by key theme F.

· Should have moved Mrs F to another nursing home immediately following her suicide attempt. This will be covered by key theme A.

· Its CHC placement team, ignored their repeated requests to urgently move Mrs F to another home. This will be covered by key theme A.

· Ignored the opinion of Mrs F’s GP and social worker on 22 July, her Community Psychiatric Nurse on 24 July, and her consultant psychiatrist on 25 July, that she should be moved to another home as soon as possible. Mr and Mrs B said the CCG’s own safeguarding lead also agreed Mrs F should be moved to a new placement. This will be covered by key theme A.

· The CHC placement team, did not provide any meaningful or timely response to their calls and emails about moving Mrs F to another nursing home. This will be covered by key theme A.

· Failed to carry out a thorough investigation into concerns raised by a social worker, following a visit on 22 July, that that Mrs F had injuries on her body. This will be covered by key themes B and D.

· Did not tell them that it decided not to move Mrs F until after that decision was made. This will be covered by key themes A and F.

· Inappropriately continued to place new service users at the nursing home despite being assured by the CCG, at a safeguarding vulnerable adults (SVA) review board meeting on 27 August, that it would not until it was satisfied the home met required standards. This will be covered by key theme D.

· Failed to invite Mr and Mrs B to a follow-up meeting in September 2019 after the SVA review board meeting, which took place at the nursing home. This will be covered by key themes A and D.

· Failed to refer Mrs F’s case for a serious incident review. This will be covered by key themes D and F.

9. In response to their complaint, Mr and Mrs B complain the CCG:

· Should have spoken to Mrs F’s GP directly about her fast track CHC funding application in June 2019, rather than the practice manager, who it asked to withdraw the application in an ‘intimidating manner’. This will be covered by key themes A and F.

· Wrongly said it was not aware Mr and Mrs B held LPA and EPA. This will be covered by key theme C.

· Continually misquoted the date the DST assessment meeting took place. This is unlikely to be directly covered by the review but there is a chance it will be covered indirectly if the review is critical of the CCG’s actions. We cannot confirm this until the review has been completed.

· Inappropriately concluded that all telephone calls and emails about moving Mrs F to another nursing home were fully responded to, without delay. This will be covered by key theme A.

· Provided an inappropriate explanation, following a decision by the council’s SVA review board on 27 August, that the CCG write to them to explain why Mrs F was not moved to another home as they requested. They also say it took the CCG too long to write to them, causing the family to chase the CCG for a response. The first part about the SVA board’s decision to ask the CCG to write to Mr and Mrs B will be covered by key theme D. The second part about how long it took the CCG to write to them would covered indirectly if the review is critical of the CCG’s actions. We cannot confirm this until the review has been completed.

· Included the terms ‘policy’ and ‘protection plan’ in its letter to them on 11 October but did not explain what this referred to. This is unlikely to be directly covered by the review but there is a chance it will be covered indirectly if the review is critical of the CCG’s actions. We cannot confirm this until the review has been completed.

10. The evidence above confirms most of the complaints Mr and Mrs B have asked us to investigate will be addressed by the SAB review. The remaining points might be addressed indirectly if the review is critical of the CCG’s actions. However, we cannot establish what issues will remain unaddressed until we know the outcome of SAB’s review. We have seen nothing which gives us cause to doubt the SAB is a suitable organisation to resolve Mr and Mrs B’s concerns.

11. In their complaint to us, Mr and Mrs B said they were seeking an open and honest explanation about what went wrong in the care arranged for Mrs F. The complainants would like the CCG to fully acknowledge that errors occurred in Mrs F’s care, and for it to apologise. They are also seeking reassurance from the CCG that action has, or will be, taken to ensure the same mistakes do not happen again in future for other service users. They are seeking compensation but do not have a figure in mind. Apart from an apology and compensation, the outcomes sought in their complaint to us are broadly similar to what the SAB review aims to provide, as set out in paragraph 4. This means the SAB review should provide Mr and Mrs B with most of the outcomes they are seeking.

12. The complaint Mr and Mrs B asked us to investigate focused on the care arranged for Mrs F by the CCG. If we were to uphold their complaint and make recommendations, these would be to the CCG. As noted above, the SAB review will involve all the organisations involved in providing, or arranging, Mrs F’s care. This means the review will have a much broader scope than an investigation by us. As noted paragraph 4, the SAB will share any learning both with local organisations as well as nationally. This means any recommendations the review might make, to address any areas of concern it finds, would lead to wider improvements in future care than any recommendation we could make. In light of this, we consider the SAB is better suited to provide the outcomes Mr and Mrs B are seeking.

13. For the reasons above, we consider that in Mr and Mrs B’s case, there is another suitable dispute resolution forum that the can reasonably pursue their complaint with. On that basis, we decline to carry out a detailed investigation of their complaint at this time. We remain open to considering their complaint again in future if they feel their concerns about the care the CCG arranged for Mrs F have not been fully addressed.

1. We have carefully considered Mr and Mrs B’s complaint about the actions taken by South West London Clinical Commissioning Group (the CCG) in arranging care for Mrs B’s late mother, Mrs F. We have decided there is another suitable dispute resolution forum Mr and Mrs B can use to obtain the outcomes they are seeking. While we are proposing to take no further action at this point, we remain open to Mr and Mrs B coming back to us in future if they remain unhappy with the response to their complaint. We have communicated this to Mr and Mrs B, and they told us they are happy with this proposal.

2. We recognise Mr and Mrs B remain unhappy with the explanations provided by the CCG about the care arranged for Mrs F. After Mr and Mrs B complained to us, another organisation they approached confirmed it would carry out a full review of the care provided to Mrs F, including the actions of the CCG. Mr and Mrs B told us they are happy for the review to consider their complaint in the first instance and then come back to us if any issues remain unaddressed. We hope the review provides Mr and Mrs B with the answers and explanations they are looking for.