Retrospective Review Success Story

This week’s success story concerns a claim period dating back to 2012, which has taken almost a decade to resolve.

The patient was admitted to care in 2010 and passed away in late-2013. She was never considered for NHS Continuing Healthcare Funding (CHC) in her lifetime, despite her extensive mental and physical health needs.

Her family approached Farley Dwek Solicitors in 2014 and asked us to investigate a retrospective claim for CHC funding to recover costs incurred by the patient for her care. Owing to the deadline imposed by the Department of Health, the claim could only be made from 1^st April 2012.

We obtained copy care and medical records and prepared a Detailed Medical Assessment. Our Nurse Assessor recommended eligibility for the full period, due to the nature, intensity and complexity of the patient’s needs.

A request for retrospective review was submitted to the then-CCG (Clinical Commissioning Group) in November 2015. As with many retrospective claims, progress was exceedingly slow as the case was passed from one third-party organisation to another. Three formal complaints were raised with the NHS due to protracted delay.

In December 2019, we finally received the CCG’s Decision Support Tool for comment, which we duly provided. Almost a year later, in November 2020, the CCG confirmed its decision that the patient was NOT eligible for CHC funding at any time during the enquiry period.

This decision was appealed, and we attended a Local Resolution Meeting with the family, acting as their advocates. At this meeting, it was identified that significant evidence had been omitted from the Decision Support Tool, which required further work. The third-party organisation dealing with the case on behalf of the CCG confirmed it would reconsider the case afresh. Over a year later, we received a letter from the CCG confirming the case had not, in fact, been reconsidered as there was no new evidence to present; the patient was NOT eligible for CHC funding.

Farley Dwek appealed the decision to NHS England, attending the Independent Review Panel with the family. Upon receipt of the casefile, it became apparent that the third-party organisation had identified substantial additional evidence at local review stage, had reassessed the case afresh and sent this to the CCG for reconsideration. A lone manager at the CCG (now renamed ‘ICB’) had decided this reconsideration was unnecessary.

The Independent Review Panel considered the evidence in the casefile, alongside verbal testimony from the family, and recommended eligibility for the full period. Almost a decade after the patient’s death, justice was finally served. The estimated recovery of care home fees wrongly paid plus back-dated interest is likely to be very substantial.

If you are battling with a retrospective claim, enduring delays, poor process and incorrect decisions, do not give up!