1.1 The complaint under investigation in this report arises from the refusal by the Health Service Executive (HSE), and subsequently by the Appeals Officer appointed under the Health (Repayment Scheme) Act 2006, to repay long-stay hospital charges under the Health Repayment Scheme (HRS). The complaint to the Ombudsman was made by Mrs. Collette Byrne, daughter of Mrs. Jean Coffey, who had made an application under the HRS, for the repayment of long-stay hospital charges (known technically as in-patient charges) which she had paid to the Health Board (later the HSE) on behalf of her mother. (With its establishment on 1 January 2005, the HSE replaced ten regional Health Boards, the Eastern Regional Health Authority, and a number of other different agencies and organisations. The period in respect of which Mrs. Byrne made the application under the HRS was 2003 and 2004, accordingly at that time, and up to 1 January 2005, she was dealing with the Northern Area Health Board (NAHB). In this report reference is made to the NAHB and to the HSE as appropriate.) The payments were made during 2003 and 2004. Her application was rejected initially by the Scheme Administrator acting for the HSE and this rejection was upheld, on appeal, by Mr. Edmund Kent, Appeals Officer. (An appeals officer appointed under the Health (Repayment Scheme) Act 2006 is subject to the jurisdiction of the Ombudsman by virtue of section 23 of that Act.) Mrs. Byrne was not happy with these decisions. She took the view that, while her mother had been a resident in a private nursing home during this period, she had been placed there by the HSE in a “contract bed" and that, accordingly, her mother was a public patient on the same basis as if she had been provided for in one of the HSE’s own hospitals or homes. (Because the supply of public long-stay nursing home beds did not meet demand, public patients were often placed in private or voluntary nursing homes by the relevant Health Board. The Health Board entered into a contractual relationship with the private or voluntary homes in respect of such patients. The bed was paid for by the Health Board, and the patient, in turn, paid charges to the Health Board on the same basis as patients in Health Board institutions. Although they were in private or voluntary homes these patients were public patients, they were referred to as being in “contract beds”.) For this reason, Mrs. Byrne believed that the payments which she had made were “recoverable charges” as provided for under the Health Repayment Scheme. Mrs. Byrne brought her complaint to the Ombudsman in May 2008.
Unfortunately, Mrs. Coffey died in February 2011, before the completion of this investigation report.
1.2 Having completed a preliminary examination of the matter, the Ombudsman decided initially to investigate the complaint arising from the Appeals Officer’s decision. The investigation focused on whether, with reference to section 4(2)(b) of the Ombudsman Act 1980, the decision of the Appeals Officer was taken on the basis of “erroneous or incomplete information” and/or whether it was “contrary to fair or sound administration”.
1.3 In examining issues related to the HRS as it affected Mrs. Coffey, it became apparent that the status of the NAHB’s arrangement with the private nursing home in which she was placed was one of the key issues in the case. Mrs. Byrne said that it was her understanding that her mother had been in a public bed which the NAHB had contracted from a private nursing home, while the HSE said that she had been in a private bed in respect of which the NAHB paid a subvention towards the cost of care. Because the issues raised necessitated an investigation of the actions of the HSE, and its agent the HRS Administrator, the Ombudsman’s investigation was extended to the Health Service Executive. The Statement of Complaint, as sent to both the Appeals Officer and the HSE, is at Appendix 1 to this report. A letter dated 29 November 2009 from Mr. Pat Whelan, Director General of this Office, to the then CEO of the HSE is attached at Appendix 2 to this report. In that letter the Director General advised the CEO that the Ombudsman’s investigation was extended to the Health Service Executive.
1.4 In investigating aspects of the case relevant to the HSE, the Ombudsman looked at:
- the involvement of the NAHB in the placement of Mrs. Coffey in a private nursing home in Co. Roscommon as well as the nature of the relationship more generally between the NAHB and the private nursing home;
- whether Mrs. Coffey was placed in the Roscommon nursing home under the care of the NAHB as opposed to being placed there as a private patient;
- the information provided by the HSE to the Scheme Administrator for the purposes of its initial decision on the HRS application as well as the working arrangements generally between the HSE and the Scheme Administrator;
- the information provided by the HSE and/or the Scheme Administrator to the Appeals Officer as well as the working arrangements generally between the HSE/Scheme Administrator and the Appeals Officer.