PFD report

Robert George MURRAY · Prevention of Future Deaths report

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Issued 23 Mar 2022•East Sussex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of understanding of circumstances when DNACPR should not be applied
    Part of recurring concern: Unreliable DNACPR decision-making, recording and communication
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Action

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

    Stated by Nursing and Midwifery CouncilStated in progressThe respondent said that this action was in progress when they made their response on 31 March 2022.
  2. Action

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

    Stated by Nursing and Midwifery CouncilStated completedThe respondent said that this action was complete when they made their response on 31 March 2022.
  3. 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 completedThe respondent said that this action was complete when they made their response on 31 March 2022.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Unreliable DNACPR decision-making, recording and communication.

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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

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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

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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

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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

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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

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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

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Ensure learning from the experience remains an ongoing topic in supervision and internal quality monitoring.

    Stated by Neighbourhood Support Team, Eastbourne & South WealdenStated plannedThe respondent said that this action was planned when they made their response on 31 March 2022.
  2. 2

    Provide all staff with refresher training in basic life support.

    Stated by Neighbourhood Support Team, Eastbourne & South WealdenStated completedThe respondent said that this action was complete when they made their response on 31 March 2022.
  3. 3

    Provide activity, kitchen and housekeeping staff with Emergency First Aid at Work training.

    Stated by Neighbourhood Support Team, Eastbourne & South WealdenStated completedThe respondent said that this action was complete when they made their response on 31 March 2022.
  4. 4

    Provide managers with CPR training through St John Ambulance sessions.

    Stated by Neighbourhood Support Team, Eastbourne & South WealdenStated completedThe respondent said that this action was complete when they made their response on 31 March 2022.
  5. 5

    Provide senior care staff with additional first-aid training on when to initiate CPR while awaiting a nurse.

    Stated by Neighbourhood Support Team, Eastbourne & South WealdenStated completedThe respondent said that this action was complete when they made their response on 31 March 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing education standards, professional requirements and revalidation arrangements are considered sufficient to ensure nurses understand DNACPR decisions.

    Stated by Nursing and Midwifery CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Ensure learning from the experience remains an ongoing topic in supervision and internal quality monitoring.

Verbatim wording from the response

“Avalon will ensure learning from this experience remain an ongoing conversation in supervision and as part of their internal monitoring of quality of service.”

Source location

Response from Adult Social Care
Page 1 · response
Published 31 March 2022

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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

Provide all staff with refresher training in basic life support.

Verbatim wording from the response

“All Staff attended refresher trainings on Basic Life support, 27th July and 14th October 2021. Senior care staff had extra training on First Aid to boost confidence on when to initiate CPR, whilst waiting for a nurse to attend. Other activity staff, including kitchen and housekeeping took courses on Emergency First Aid at Work on 18th May 2022.”

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

Provide activity, kitchen and housekeeping staff with Emergency First Aid at Work training.

Verbatim wording from the response

“All Staff attended refresher trainings on Basic Life support, 27th July and 14th October 2021. Senior care staff had extra training on First Aid to boost confidence on when to initiate CPR, whilst waiting for a nurse to attend. Other activity staff, including kitchen and housekeeping took courses on Emergency First Aid at Work on 18th May 2022.”

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

Provide managers with CPR training through St John Ambulance sessions.

Verbatim wording from the response

“The managers attended CPR sessions by St Johns Ambulance on behalf of ‘Restart a heart day’ on the 14th of October 2021 and 18th of February 2022.”

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

Provide senior care staff with additional first-aid training on when to initiate CPR while awaiting a nurse.

Verbatim wording from the response

“All Staff attended refresher trainings on Basic Life support, 27th July and 14th October 2021. Senior care staff had extra training on First Aid to boost confidence on when to initiate CPR, whilst waiting for a nurse to attend. Other activity staff, including kitchen and housekeeping took courses on Emergency First Aid at Work on 18th May 2022.”

Source location

Response from Adult Social Care
Page 1 · response
Published 31 March 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

Existing education standards, professional requirements and revalidation arrangements are considered sufficient to ensure nurses understand DNACPR decisions.

Verbatim wording from the response

“Education institutions are expected to ensure the curriculum they design allow the students to achieve the above standards of proficiency. We therefore expect registered nurses at the point of registration to have the knowledge and skills of DNACPRs as part of their pre-registration education.”

Source location

Response from Nursing Midwifery Council
Page 4 · response
Published 31 March 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026