ICB Decision Appeal

This week’s success story concerns a patient who sustained a considerable pressure injury having been left in an unsuitable chair for too long by the nursing home. Staff had accepted his decisions to decline repositioning, notwithstanding Mental Capacity Assessments confirming he was unable to make informed choices about this care due to a severe cognitive impairment.

Despite the fist-sized, necrotic wound having been graded by the Tissue Viability Nurse only days earlier as a category FOUR ulcer, extending to the underlying tendons or bone, the Multi-Disciplinary Team (MDT) assessed only a ‘High’ level of need in the Skin domain. The stated rationale that the wound was “responding to treatment” confirmed a clear misapplication of the descriptors on the Decision Support Tool.

Problems with wound healing were further compounded by severe contractures, lack of sitting balance, lower limb spasticity and spasms.

The Nurse Assessor unilaterally reduced the assessed ‘Severe’ level of need in the Cognition domain to ‘High’ after the MDT, without discussing with the Social Worker, following a review of care plans, ignoring the Mental Capacity Assessments and Deprivation of Liberty Order.

Despite the unequivocal complexity of the patient’s needs, the ICB ratified the recommendation of the MDT that he did not meet the criteria for CHC funding.

Farley Dwek were instructed to appeal the decision on behalf of the family, obtaining detailed records and photographs by the Tissue Viability Nurse which contradicted much of the contents of the nursing home’s inaccurate documentation about the pressure ulcer. Detailed Written Submissions were provided to the NHS Integrated Care Board (ICB) in support of the appeal.

Following a brief Local Resolution Meeting, the ICB overturned the decision of ineligibility within 24-hours, correctly increasing the level of need in both the Skin and Cognition domains to ‘Severe’.