Mr Frank Mellers · Prevention of Future Deaths report

On 23 September 2015, I commenced an investigation into the death of Mr Frank Mellers (dob 18/9/21). The investigation concluded at the end of the inquest on 17 November 2015. The conclusion of the inquest was a narrative conclusion:

Mr Mellers had a fall at home on the 4 September 2015 and sustained a fractured left hip. He was admitted to Hospital the same day and had an operation to repair the fracture on the 16 September 2015. Post operatively he initially made good recovery and a do not attempt resuscitation notice (DNAR) was in place prior to surgery. There were a number of occasions of poor communication with the family of the deceased where little or no explanation was given to the family as to his actual DNAR status. In addition he was thought to be not classified as DNAR by nursing staff and CPR was commenced when his condition declined and he suffered a cardiac arrest on the 17 September 2015. He was initially resuscitated and then had a further heart attack and on this second occasion, CPR was not commenced and he died on the 17 September 2015 as a result of congestive cardiac failure, Ischaemic heart disease contributed to by the stress of the necessary operation to repair the fracture.

The medical cause of death was 1a) Congestive cardiac failure 1b) Ischaemic heart disease 1c) Post-operative repair of fracture neck of femur.

The circumstances are apparent from the conclusion outlined above.

(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.