Recurring concern

Unreliable DNACPR decision-making, recording and communication

First to latest report 7 Jan 2014 — 14 Aug 2023

Reports that mention this concern: 13
Times this concern has been raised: 15
Stated actions linked to this concern: 21

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, 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

Reports and published responses 13 reports

See individual reports that have raised this concern, and the actions taken in response

9 Jun2014
Oxfordshire
Concerns raised2
1. Failure to retrieve and clearly mark expired or non-renewed DNA CPR forms
2. Failure to ensure that DNA CPR form wording is read and understood correctly
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

NHS England (Thames Valley Area Team
Respondent positions 1
1. NHS England (Thames Valley Area Team
  The CCG is responsible for holding the hospital Trust to account for learning from the inquest and compliance with DNACPR policy.
  Redirects responsibility
AI-generated summary

John Cook · 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

John Cook, a 73-year-old man receiving palliative care in a nursing home, experienced severe breathing difficulty and died on 6 October 2012. Ambulance personnel believed a Do Not Attempt Resuscitation form was in effect, but it had expired when he was discharged from hospital. The report raised concerns about unclear form wording, failure to retrieve or mark expired forms, difficulty identifying the issuing hospital, and communication failures that led to an unnecessary inquest and police investigation, although the report stated these failures did not affect the outcome.

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 retrieve and clearly mark expired or non-renewed DNA CPR forms
Wider context from the report
“(2) Under Section 3 headed Review there is “Decision valid to date of discharge from hospital”. I understand that this is an unusual form of wording. Normally an expiry date would be specified which seems to me to be good practice, however, once an expiry date has been reached and if there is no renewal, it seems to me that to avoid confusion, it would be better if the form were retrieved and clearly marked ‘Cancelled’, ‘Expired’ or some similar wording. In this particular case, given the wording used on the form, I think it should never have left the hospital. In this particular case, there was failure to read and/or understand the wording used and those attending reduced that the fall-back position was not to attempt resuscitation when the opposite was the correct interpretation. The difficulties were compounded by the quality of English spoken by some concerned but this is not uncommon and should be allowed for. Having said this, I am satisfied that these failures of communication did not affect the outcome and that any attempt at resuscitation would have been quite futile. It did however mean that an Inquest which should have been unnecessary had to be conducted, there was an unnecessary Police investigation and, of course, consequent distress to the family. ”
Source location
John Cook · Prevention of Future Deaths report
Page 2 · 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 to ensure that DNA CPR form wording is read and understood correctly
Wider context from the report
“(2) Under Section 3 headed Review there is “Decision valid to date of discharge from hospital”. I understand that this is an unusual form of wording. Normally an expiry date would be specified which seems to me to be good practice, however, once an expiry date has been reached and if there is no renewal, it seems to me that to avoid confusion, it would be better if the form were retrieved and clearly marked ‘Cancelled’, ‘Expired’ or some similar wording. In this particular case, given the wording used on the form, I think it should never have left the hospital. In this particular case, there was failure to read and/or understand the wording used and those attending reduced that the fall-back position was not to attempt resuscitation when the opposite was the correct interpretation. The difficulties were compounded by the quality of English spoken by some concerned but this is not uncommon and should be allowed for. Having said this, I am satisfied that these failures of communication did not affect the outcome and that any attempt at resuscitation would have been quite futile. It did however mean that an Inquest which should have been unnecessary had to be conducted, there was an unnecessary Police investigation and, of course, consequent distress to the family. ”
Source location
John Cook · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 CCG is responsible for holding the hospital Trust to account for learning from the inquest and compliance with DNACPR policy.

Verbatim wording from the response
“Clearly it is of upmost importance that the DNACPR policy is followed correctly and the Oxfordshire Clinical Commissioning Group (CCG) have been working with Oxford University Hospital NHS Trust (OUH) to ensure that this happens. OUH carry out regular training sessions and complete regular audits in relation to the completion of the whole DNACPR process which includes effective completion of the policy. We have requested that the CCG share the results of the audits with us. We are assured that the CCG will hold the Trust to account in relation to the learning from this inquest.”

Source location
2014-0578-Response-by-NHS-england_Redacted
Page 2 · response
Published 9 June 2014
Open published response
30 Apr2014
Nottinghamshire
Concerns raised1
1. Lack of nursing staff understanding of DNACPR forms and required completion information
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Sycamore Horizon Ltd
Stated actions 2
1. Sycamore Horizon Ltd
  Require a GP-signed DNAR form on a service user's file for the DNAR decision to be effective.
2. Sycamore Horizon Ltd
  Review newly admitted service users with existing DNAR decisions and obtain an appropriate GP-signed DNAR form where required.
AI-generated summary

Beryl French · 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

Beryl French was a resident at Landmere Nursing Home who developed respiratory difficulties while receiving personal care. Nursing staff did not initiate active interventions because they believed a completed DNACPR form was in place, but no such form existed. The concerns included staff understanding of DNACPR forms and insufficient end-of-life care planning.

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 nursing staff understanding of DNACPR forms and required completion information
Wider context from the report
“1. That there was a lack of understanding amongst nursing staff at Landmere about the nature of DNACPR forms and the information that should be provided for them to be complete and appropriate to be relied upon. Although the evidence disclosed that no active intervention would have saved Mrs French, and that in was in her best interests not to intervene, this might not be the case in other, similar circumstances. ”
Source location
Beryl French · 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
Require a GP-signed DNAR form on a service user's file for the DNAR decision to be effective.

Verbatim wording from the response
“Life Style Care Plc now require a DNAR form signed by a GP to be in place on a service user's file in order for it to be effective. Life Style Care Plc is not able to develop its own DNAR form because homes in different regions and boroughs are often required to use a particular DNAR form which is individual to that particular local health authority. With a DNAR form signed by a GP in place this provides clarity to both staff and paramedics about the status of the service user.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 2 · response
Published 30 April 2014
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
Review newly admitted service users with existing DNAR decisions and obtain an appropriate GP-signed DNAR form where required.

Verbatim wording from the response
“If a service user is admitted to a Life Style Care Plc home from hospital or another care setting with a DNAR in place then they are reviewed by a GP and a nurse and if appropriate a DNAR form is produced and signed by the GP.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 2 · response
Published 30 April 2014
Open published response
7 Jan2014
Manchester South
Concerns raised1
1. Failure to verify the correct DNAR status
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

James Hadfield Withers · 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 Hadfield Withers died on 27 January 2013 after surgery for invasive colonic adenocarcinoma, with the inquest recording congestive cardiac failure associated with diseased heart and the stress of the operation. Concerns included a five-day delay in cardiology review, missing medical and nursing notes, incorrect recording of DNAR status, and poor communication among staff and with the family.

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 verify the correct DNAR status
Wider context from the report
“4. One of the doctors admitted that he had assumed an incorrect DNAR status based on the fact that he had two separate pieces of paper in his pocket and had looked at the wrong one. ”
Source location
James Hadfield Withers · Prevention of Future Deaths report
Page 2 · concerns
Open source report