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Successful intervention by the Health Ombudsman following incorrect refusal by the ICB to review a retrospective period

Following the patient’s passing, we had contacted the responsible Integrated Care Board (‘ICB’) to request a retrospective review of a two-year period, with the view of recovering the care fees which had been incurred throughout this time. We gathered medical evidence and drafted comprehensive representations, which supported an entitlement to CHC funding for this period.

However, the ICB initially refused our request for a retrospective review on the basis that a DST assessment had previously been completed for the patient prior to the period in question for the retrospective review, and a further review was undertaken during the period, which determined that a further full assessment was not needed. The family had not been informed at the time that this review could be appealed, however the NHS were refusing our request for a retrospective review now on the basis that the review was not appealed. We disputed this approach through the ICB’s complaints process, however they upheld their decision to refuse our retrospective review request.

We therefore contacted the Parliamentary and Health Service Ombudsman to lodge a complaint against the ICB’s decision. After reviewing our complaint and the medical evidence we had obtained in support of the case, the Ombudsman discussed the case with the NHS, who subsequently agreed to proceed with a retrospective review for the period after the review assessment up until the patient’s passing, providing us with the potential to recover care fees for a period of one year.

Such a case highlights how it can be possible to overcome the obstacles faced when dealing with the NHS, as the Ombudsman are willing to intervene and direct the NHS accordingly when it is clear that the correct process has not been followed. Whilst we always attempt to resolve any disputes first via the NHS’ internal complaints process, there is the option to progress matters to the Ombudsman if necessary and this can result in a favourable outcome.

If you have a relative who you believe should have been entitled to CHC funding, you should contact us immediately for a free, confidential assessment as to their entitlement to Continuing Healthcare Funding.

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