Recurring concern

Unreliable DNACPR decision-making, recording and communication

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First reported 7 Jan 2014•Latest report 14 Aug 2023

Definition

What this concern includes

Includes failures in deciding when DNAR or DNACPR applies, completing or maintaining the record, identifying or verifying the current status and communicating the decision between relevant staff.

Not included

Broader resuscitation or end-of-life care failures where DNAR or DNACPR is not the deficient control.
Failure to act on a correctly made, recorded and communicated DNACPR decision.
Other advance-care-planning processes unless the assertion specifically concerns DNAR or DNACPR status.

Reports: 13
Individual concerns: 15
Date range: 2014–2023
Stated actions: 21

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission3

Association of Ambulance Chief Executives2

Walsall Manor Hospital2

Anson Court Residential Home1

Barking, Havering and Redbridge University Hospitals NHS Trust1

Collingwood Grange Care Home1

Department of Health and Social Care1

Downham Grange1

Healthcare Management Solutions Ltd1

Kingsley Care Homes Limited1

Leonard Cheshire Disability1

NHS England1

Nursing and Midwifery Council1

Recipient name withheld1

Rossmere Park Care Centre1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

14 Aug2023
Surrey
Concerns raised1
1. Failure to accurately communicate DNAR status to the ambulance service
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Maintain a robust handover process for communicating concerns about supported people.
  Stated by Leonard Cheshire DisabilityStated completed
2. Action
  Implement an additional discreet system at Hydon Hill to identify people who do not want resuscitation.
  Stated by Leonard Cheshire DisabilityStated completed
AI-generated summary

Linda Oldland · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Linda Oldland died at Hydon Hill Nursing Home on 3 January 2022 from a urinary tract infection that infected both kidneys and resulted in sepsis. Concerns included failures to share information about positive urine tests and the GP’s treatment plan, delayed antibiotics, failure to recognise cardiac arrest, and incorrectly informing ambulance staff that a valid DNAR form was in place.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to accurately communicate DNAR status to the ambulance service
Wider context from the report
“Hydon Hill Nursing Home: - Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021; - Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022; - Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis; - Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022; - Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022. The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters. ”
Source location
Linda Oldland · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain a robust handover process for communicating concerns about supported people.

Verbatim wording from the response
“In addition to the action plan above, we have a robust handover process which is an opportunity to discuss any concerns the nurses and carers have with people, which people have a Respect document in-situ and who does not want to be resuscitated. Hydon Hill specifically have implemented an additional system to identify discreetly who does not want to be resuscitated, this ensures that if a person is not in their bedroom but around the home in their wheelchair, staff can easily identify them, should they need to.”

Source location
Response from Leonard Cheshire
Page 2 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement an additional discreet system at Hydon Hill to identify people who do not want resuscitation.

Verbatim wording from the response
“In addition to the action plan above, we have a robust handover process which is an opportunity to discuss any concerns the nurses and carers have with people, which people have a Respect document in-situ and who does not want to be resuscitated. Hydon Hill specifically have implemented an additional system to identify discreetly who does not want to be resuscitated, this ensures that if a person is not in their bedroom but around the home in their wheelchair, staff can easily identify them, should they need to.”

Source location
Response from Leonard Cheshire
Page 2 · response
Published 6 September 2023
Open published response
8 Jun2022
Norfolk
Concerns raised1
1. Failure to maintain clear records of DNACPR and ReSPECT status
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Revise DNACPR and ReSPECT procedures to scan forms into PCS, retain paper originals securely, and provide electronic hospital packs without releasing originals.
  Stated by Kingsley Care Homes LimitedStated completed
2. Action
  Train staff on the revised DNACPR and ReSPECT procedure, including form completion, associated care plans, and use of electronic hospital packs.
  Stated by Kingsley Care Homes LimitedStated completed
3. Action
  Audit homes to confirm DNACPR and ReSPECT forms are uploaded, contact relevant families, and visually flag form status within PCS.
  Stated by Kingsley Care Homes LimitedStated completed
AI-generated summary

Lilian Bernadette BEHRENDT · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Lilian Bernadette Behrendt, aged 91, deteriorated at her care home on 28 November 2021 and died later that evening after being taken to hospital, where she was diagnosed with chest sepsis. The report raised concerns about an incorrectly graded ambulance call, records describing her as “content” despite deterioration, missing observation results, uncertainty about DNACPR and ReSPECT documentation, and unclear responsibility and accountability within the care home.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain clear records of DNACPR and ReSPECT status
Wider context from the report
“5) It was unclear from the Home records whether a DNACPR and a ReSPECT form were in place. The Manager had not seen a paper copy and was unclear as to the position. ”
Source location
Lilian Bernadette BEHRENDT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Revise DNACPR and ReSPECT procedures to scan forms into PCS, retain paper originals securely, and provide electronic hospital packs without releasing originals.

Verbatim wording from the response
“To avoid a repeat of this possible situation, the Company has revised its system to ensure that DNACPR and ReSPECT forms are retained at all times. For example, if a service user is admitted to Downham Grange from hospital, the relevant DNACPR/ReSPECT form will accompany them to the Home in paper form. Conversely, if a service user is already resident within the Home and is placed on end of life care, the GP will complete the relevant form. In both instances, the paper form is now scanned and uploaded into the PCS. The paper versions will also be retained in each service user’s dedicated papers file, which is kept in the Home Manager’s office.”

Source location
Response from Kingsley Healthcare
Page 5 · response
Published 16 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train staff on the revised DNACPR and ReSPECT procedure, including form completion, associated care plans, and use of electronic hospital packs.

Verbatim wording from the response
“Following Mrs Behrendt’s death the Company has provided all staff with training on the new procedure and has specifically directed them that original paper documentation is not to be supplied to ambulance crews, and that instead the electronic hospital pack must be printed from the PCS.”

Source location
Response from Kingsley Healthcare
Page 5 · response
Published 16 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit homes to confirm DNACPR and ReSPECT forms are uploaded, contact relevant families, and visually flag form status within PCS.

Verbatim wording from the response
“To ensure that all forms within its homes have been uploaded, audits have been undertaken at each site to identify all service users in receipt of the same. All families of service users with these forms in place have been contacted, to ensure that they are aware of their existence. In addition, to identify at a glance which service users have a DNACPR/ReSPECT form in place, the PCS has been updated and the relevant section is now highlighted in red for those service users with a DNACPR in place; and blue for those without a DNACPR in place.”

Source location
Response from Kingsley Healthcare
Page 5 · response
Published 16 September 2022
Open published response
25 May2022
East London
Concerns raised1
1. Poor medical record-keeping and documentation of do-not-attempt-CPR decisions
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Ratify a new DNACPR policy.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated planned
Respondent positions 1
1. Position
  The current DNACPR policy sufficiently requires communication, documentation and regular review of CPR decisions.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustExisting arrangements considered sufficient
AI-generated summary

Elizabeth Margaret Mills · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Elizabeth Margaret Mills was admitted to hospital with abdominal pain on 25 March 2021, underwent surgery for a perforated pyloric ulcer, and later developed pneumonia requiring increasing oxygen therapy. She died after removing an oxygen mask while unattended in a side ward, when nasal cannulae were replaced but were no longer connected to an oxygen supply. Concerns included poor medical record-keeping about the do-not-attempt-CPR process, reliance on her husband to keep the mask in place, and the Trust’s failure to investigate unexpected events through a Serious Incident Investigation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor medical record-keeping and documentation of do-not-attempt-CPR decisions
Wider context from the report
“1. The poor standard of medical record-keeping and documentation did not allow a clear understanding of whether the Trust policy on “Do not attempt CPR” orders was followed properly. Family members assert that the process was not properly engaged and their views were not explored. ”
Source location
Elizabeth Margaret Mills · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ratify a new DNACPR policy.

Verbatim wording from the response
“The Trust is satisfied that the current policy (attached to this response) clearly sets out the need for clear communication about DNACPR with the patient and those close to them, together with the need for clear documentation on DNACPR decisions and the requirement for regular review of DNACPR decisions. I am sorry that the documentation in this case did not allow a clear understanding of whether the Trust policy on DNACPR orders was correctly followed. The Trust intends to ratify a new DNACPR policy in August 2022. Policies undergo rigorous drafting with stakeholder engagement, to aid richer development. Policies are disseminated across the Trust in discussion by virtual meetings, relevant forums such as Quality and Safety meetings, emails cascaded by Divisional teams and through briefings by the Communications Team.”

Source location
Response from NHS Barking, Havering and Redbridge University Hospital
Page 2 · response
Published 16 September 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The current DNACPR policy sufficiently requires communication, documentation and regular review of CPR decisions.

Verbatim wording from the response
“The Trust is satisfied that the current policy (attached to this response) clearly sets out the need for clear communication about DNACPR with the patient and those close to them, together with the need for clear documentation on DNACPR decisions and the requirement for regular review of DNACPR decisions. I am sorry that the documentation in this case did not allow a clear understanding of whether the Trust policy on DNACPR orders was correctly followed. The Trust intends to ratify a new DNACPR policy in August 2022. Policies undergo rigorous drafting with stakeholder engagement, to aid richer development. Policies are disseminated across the Trust in discussion by virtual meetings, relevant forums such as Quality and Safety meetings, emails cascaded by Divisional teams and through briefings by the Communications Team.”

Source location
Response from NHS Barking, Havering and Redbridge University Hospital
Page 2 · response
Published 16 September 2022
Open published response
23 Mar2022
East Sussex
Concerns raised1
1. Lack of understanding of circumstances when DNACPR should not be applied
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Introduce and establish Future Nurse standards of proficiency, including requirements covering end-of-life care and DNACPR decisions.
  Stated by Nursing and Midwifery CouncilStated completed
2. Action
  Approve all UK pre-registration nursing programmes against the Future Nurse standards.
  Stated by Nursing and Midwifery CouncilStated completed
3. Action
  Monitor approved education institutions and their delivery of nursing education programmes through quality assurance activities.
  Stated by Nursing and Midwifery CouncilStated in progress
1. Action
  Update DNACPR and RESPECT advice and include it in relevant care plans.
  Stated by Neighbourhood Support Team, Eastbourne & South WealdenStated completed
2. Action
  Discuss clinical judgements on RESPECT and DNACPR initiatives with the local surgery and paramedic practitioners.
  Stated by Neighbourhood Support Team, Eastbourne & South WealdenStated completed
3. Action
  Change the ambulance-calling and DNACPR policies to reflect current and ongoing practice learning.
  Stated by Neighbourhood Support Team, Eastbourne & South WealdenStated completed
AI-generated summary

Robert George MURRAY · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Robert George MURRAY, who had mild dementia and lived in a nursing home, choked on food at breakfast on 10 June 2021 and died. An ambulance was not sent because he had a DNACPR in place; the concern was that those involved did not understand when a DNACPR should not be applied, indicating a need for further training and clarification.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of understanding of circumstances when DNACPR should not be applied
Wider context from the report
“From listening to the 999 call between the registered nurse at the care home and the call operator, and also from evidence heard at the inquest, it is apparent that no one involved understood that there are circumstances when the DNACPR should not be applied. I am concerned that this may potentially be an issue elsewhere in the country and further training and clarification is therefore necessary. ”
Source location
Robert George MURRAY · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce and establish Future Nurse standards of proficiency, including requirements covering end-of-life care and DNACPR decisions.

Verbatim wording from the response
“In 2016 we embarked on a significant programme of change in relation to all of our education and training standards, which has included revising our standards of proficiency for registered nurses and midwives to strengthen public protection and continue to make sure that they are fit for purpose. We introduced new standards of proficiency for registered nurses in 2018 (described as the Future Nurse standards⁶).”

Source location
Response from Nursing Midwifery Council
Page 3 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Approve all UK pre-registration nursing programmes against the Future Nurse standards.

Verbatim wording from the response
“The Future Nurse standards were approved by our Council following extensive consultation and engagement over a two year period. All pre-registration programmes in the UK have been approved against the new Future Nurse standards. We expect the first nurses will graduate under these new standards in 2022.”

Source location
Response from Nursing Midwifery Council
Page 3 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor approved education institutions and their delivery of nursing education programmes through quality assurance activities.

Verbatim wording from the response
“Nursing and midwifery professionals can demonstrate that they have met these standards of proficiency by completing approved qualifications as part of a pre-registration education programmes that have been approved by us in the UK. We set wider standards for nursing and midwifery education and programme standards⁴ which enable our approved education institutions to deliver programmes related to the relevant standards of proficiency. The approved education institutions will design their curricula to be able to meet our standards. We approve programmes and monitor the education institutions and their programme delivery as part of our Quality Assurance”

Source location
Response from Nursing Midwifery Council
Page 2 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update DNACPR and RESPECT advice and include it in relevant care plans.

Verbatim wording from the response
“It was mentioned at the planning meeting that you had already held a Pre-Inquest Review (PIR) meeting with Avalon on 18th November 2021 and advice related to DNACPR and RESPECT forms had been updated and included in all care plans, where necessary. Avalon also held a discussion with local surgery, Park Practice and Paramedic Practitioners regarding clinical judgements related to RESPECT and DNACPR initiatives.”

Source location
Response from Adult Social Care
Page 1 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss clinical judgements on RESPECT and DNACPR initiatives with the local surgery and paramedic practitioners.

Verbatim wording from the response
“It was mentioned at the planning meeting that you had already held a Pre-Inquest Review (PIR) meeting with Avalon on 18th November 2021 and advice related to DNACPR and RESPECT forms had been updated and included in all care plans, where necessary. Avalon also held a discussion with local surgery, Park Practice and Paramedic Practitioners regarding clinical judgements related to RESPECT and DNACPR initiatives.”

Source location
Response from Adult Social Care
Page 1 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Change the ambulance-calling and DNACPR policies to reflect current and ongoing practice learning.

Verbatim wording from the response
“Avalon also made changes to their policy on ‘Calling an ambulance’ and DNACPR (see attached) to reflect current and ongoing practice learning.”

Source location
Response from Adult Social Care
Page 1 · response
Published 31 March 2022
Open published response
16 Sep2021
Black Country
Concerns raised1
1. Poor procedures for identifying residents' DNAR status
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs Tripta Bhanote · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mrs Tripta Bhanote, who was 86 and living in a residential care home, was found on the floor on several occasions in May 2020 and her condition then declined rapidly before she died. Concerns included unclear procedures for escalating acute illness to emergency services, uncertainty about referral to the enhanced care and quality team, and poor procedures for identifying residents’ DNAR status.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor procedures for identifying residents' DNAR status
Wider context from the report
“3. There was evidence of poor procedures in place in identifying the DNAR status of residents. ”
Source location
Mrs Tripta Bhanote · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jan2021
Wiltshire and Swindon
Concerns raised1
1. Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Continue responding to DNAR/TEP risks through routine regulatory monitoring and inspection during the consultation period.
  Stated by Care Quality CommissionStated in progress
AI-generated summary

Vhari Ingall · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Vhari Ingall died from an oxycodone drug overdose, with the inquest returning a conclusion of suicide. The principal concerns were the failure to review an outdated Treatment Escalation Plan/Do Not Resuscitate form after her diagnosis changed, and whether healthcare professionals and emergency services could access accurate and current information about such forms.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making
Wider context from the report
“The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate. In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present. I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information. B) DEPARTMENT OF HEALTH Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners. These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend. ”
Source location
Vhari Ingall · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue responding to DNAR/TEP risks through routine regulatory monitoring and inspection during the consultation period.

Verbatim wording from the response
“We continue to respond to risk via routine monitoring and inspection during this consultation period, including concerns and issues raised in this report.”

Source location
2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
Page 3 · response
Published 20 April 2020
Open published response
28 May2019
Teesside and Hartlepool
Concerns raised1
1. Lack of clarity about the existence of a DNA CPR
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement a DNACPR notification system using door markers and prominent notices in residents’ room folders.
  Stated by Rossmere Park Care CentreStated completed
AI-generated summary

Gloria Elizabeth MEKINS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Gloria Elizabeth Mekins was a resident at Rossmere Park Care Home when she choked while eating a snack on 2 October 2018 and died at the care home. Concerns included the absence of first aid by the staff member who found her, confusion about the existence of a DNA CPR leading to a delay in first aid, and the care home's failure to investigate or address these issues.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity about the existence of a DNA CPR
Wider context from the report
“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”
Source location
Gloria Elizabeth MEKINS · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a DNACPR notification system using door markers and prominent notices in residents’ room folders.

Verbatim wording from the response
“Staff are advised which resident has a DNACPR Notice by means of a whiteboard within the Nurse’s office at Rossmere Park Care Centre – with the same facility in the Senior’s office on the Ground Floor. This shows against each resident’s room, whether a DNACPR is in place and the date it expires. The Daily Handover sheets also show clearly against each room which resident has a DNACPR.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 2 · response
Published 2 August 2019
Open published response
25 Jan2017
Surrey
Concerns raised1
1. Insufficient staff understanding of when potentially life-saving treatment should be provided under a DNAR order
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Geraldine Butterfield · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Geraldine Butterfield died on 25 July 2015 after choking on food while eating lunch at a nursing home; the cause of death was recorded as asphyxia due to food inhalation. Concerns were raised that some nursing staff did not sufficiently understand or implement the choking policy, and did not sufficiently understand when potentially life-saving treatment should be provided to a person with a DNAR order.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient staff understanding of when potentially life-saving treatment should be provided under a DNAR order
Wider context from the report
“Having heard evidence from a number of members of the nursing staff, I am concerned that not all staff members have a sufficient knowledge and understanding of the BUPA policy on choking, so as to be able to effectively implement it in the future. I am also concerned that not all staff members have a sufficient understanding of when potentially life-saving treatment should be provided to individuals in respect of whom a DNAR order is in place. - Not all staff members have a sufficient knowledge and understanding of the BUPA policy on choking so as to be able to effectively implement it in the future. - Not all staff members have a sufficient understanding of when potentially life-saving treatment should be provided to individuals in respect of whom a DNAR order is in place. Consideration should be given to whether any steps, including further training, can be taken to address the above concerns. ”
Source location
Geraldine Butterfield · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Feb2016
Portsmouth and South East Hampshire
Concerns raised1
1. Failure to make residents' DNACPR status promptly accessible to responding staff
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

James Robertson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

James Robertson died on 22 July 2015 while resident at Cams Ridge Care Home, after he was last checked at around 13.00 hours and found apparently deceased at around 15.30 hours. Concerns included inaccurate recording of care-check times, delayed recognition of his DNACPR status, and inadequate equipment in the emergency resuscitation pack, particularly the lack of a suction unit.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to make residents' DNACPR status promptly accessible to responding staff
Wider context from the report
“2) I was also told that whether a resident at Cams Ridge was covered by DNACPR was indicated by a coloured sticker on the door of the resident's room and in centrally-located notes. The sticker on the door was not appreciated by a nurse who attended to him when he was found unresponsive and who then went to look in his notes, delaying resuscitation efforts. I was told that it would be better if DNACPR status was included on a resident's shift hand over notes which would be more quickly accessible than the centrally-located notes. ”
Source location
James Robertson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
17 Nov2015
Black Country
Concerns raised2
1. Failure to communicate DNAR decisions to the patient’s family
2. Failure of nursing and medical staff to communicate DNAR decisions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review the DNAR policy for compliance with best practice, including communication requirements.
  Stated by Walsall Healthcare NHS TrustStated completed
2. Action
  Develop a leaflet giving patients and families information about DNAR decisions.
  Stated by Walsall Healthcare NHS TrustStated completed
3. Action
  Conduct peer audits of DNAR form use and continue reviewing them on a rolling basis to assure implementation of disseminated learning.
  Stated by Walsall Healthcare NHS TrustStated in progress
1. Action
  Reiterate the ward-round standard requiring daily joint nursing and medical staff rounds.
  Stated by Walsall Healthcare NHS TrustStated completed
2. Action
  Develop a Ward Board indicator highlighting patients with DNAR decisions for staff handovers and ongoing reference.
  Stated by Walsall Healthcare NHS TrustStated completed
AI-generated summary

Mr Frank Mellers · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Frank Mellers fell at home on 4 September 2015, fractured his left hip, and was admitted to hospital for surgery. He suffered a cardiac arrest on 17 September 2015 and died that day from congestive cardiac failure, with ischaemic heart disease and the post-operative fracture repair recorded as contributing factors. The concerns included poor communication with his family about his DNAR status and poor communication between nursing and medical staff, including CPR being commenced despite a DNAR being in place.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate DNAR decisions to the patient’s family
Wider context from the report
“(1) Evidence emerging from the inquest suggested that the patient’s DNAR status was fixed without any reference to/discussion with his family. It is recognised that this is a medical decision for the physician but good practice and guidelines require that the family be kept up to date with all such decisions. (2) There was generally poor communication between nursing and medical staff as evidenced during the inquest when a decision was made to attempt resuscitation despite there being a DNAR in place. (3) In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined. ”
Source location
Mr Frank Mellers · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of nursing and medical staff to communicate DNAR decisions
Wider context from the report
“(1) Evidence emerging from the inquest suggested that the patient’s DNAR status was fixed without any reference to/discussion with his family. It is recognised that this is a medical decision for the physician but good practice and guidelines require that the family be kept up to date with all such decisions. (2) There was generally poor communication between nursing and medical staff as evidenced during the inquest when a decision was made to attempt resuscitation despite there being a DNAR in place. (3) In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined. ”
Source location
Mr Frank Mellers · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the DNAR policy for compliance with best practice, including communication requirements.

Verbatim wording from the response
“• We reviewed our policy to ensure that it is compliant with best practice (including communication) with regard to DNAR.”

Source location
Frank-Mellers-Response
Page 2 · response
Published 17 November 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a leaflet giving patients and families information about DNAR decisions.

Verbatim wording from the response
“• We have developed a leaflet to provide patients and families with information about DNAR (enc).”

Source location
Frank-Mellers-Response
Page 2 · response
Published 17 November 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct peer audits of DNAR form use and continue reviewing them on a rolling basis to assure implementation of disseminated learning.

Verbatim wording from the response
“• We have undertaken over the past several months a series of peer audits throughout a variety of care settings to review the effectiveness with which DNAR forms are being utilised. I am pleased to report that during this period we have seen significant improvements in the quality, completeness and robustness of the use of DNAR with particular emphasis placed upon ensuring discussions with patients and their families are clear and fully documented about the purpose and potential outcome of a DNAR. We will be carrying out these audits and reviews on a rolling basis to assure that the learning from this incident which we have disseminated across our organisation.”

Source location
Frank-Mellers-Response
Page 2 · response
Published 17 November 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reiterate the ward-round standard requiring daily joint nursing and medical staff rounds.

Verbatim wording from the response
“• We have reiterated the importance of the use of our ward round standard which emphasises the importance of daily ward rounds to be carried out between both staff groups to ensure strong and robust care management.”

Source location
Frank-Mellers-Response
Page 2 · response
Published 17 November 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a Ward Board indicator highlighting patients with DNAR decisions for staff handovers and ongoing reference.

Verbatim wording from the response
“• We have developed an indicator on our Ward Boards to ensure that where a patient has a DNAR in place it is highlighted to all staff. The Ward Boards act as a communication tool to allow for fast reference by all staff groups during handovers and during the course of the day.”

Source location
Frank-Mellers-Response
Page 2 · response
Published 17 November 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to accurately communicate DNAR status to the ambulance service

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to maintain clear records of DNACPR and ReSPECT status

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Poor medical record-keeping and documentation of do-not-attempt-CPR decisions

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of understanding of circumstances when DNACPR should not be applied

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised1

Poor procedures for identifying residents' DNAR status

Concerns raised1

Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Lack of clarity about the existence of a DNA CPR

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Insufficient staff understanding of when potentially life-saving treatment should be provided under a DNAR order

Concerns raised1

Failure to make residents' DNACPR status promptly accessible to responding staff

Actions described in response 2

Actions described in response 3

Actions described in response 1

Respondent positions 1

Actions described in response 6

Actions described in response 1

Actions described in response 1