John Elvet Morgan · Prevention of Future Deaths report

On 9th September 2013 I commenced an investigation into the death of John Elvet Morgan aged 88. The investigation concluded at the end of the inquest on 26th November 2013. The medical cause of death was: 1a Pulmonary Embolism in a man with dementia of Alzheimer’s type, and the conclusion of the inquest was that the deceased died from natural causes.

John Elvet Morgan was admitted to St Barruc’s ward, Barry hospital on 29th August 2013 for respite care. He suffered from Alzheimer’s dementia. On admission a red DNR (Do not Resuscitate) star was allowed to remain against his name on the whiteboard (or PSAG “Patient status at a glance Board”) on the ward. In fact there had been no agreement that he was “DNR” and the red star had been left over by mistake from a previous patient’s entry on the whiteboard. On 30th August 2013 John Elvet Morgan collapsed on the ward. He was not resuscitated by staff on the ward as they relied on the red “DNR” star on the whiteboard. When the paramedics arrived no yellow DNR form was found in the notes as of course one did not exist. The PM report showed that John Elvet Morgan had suffered a pulmonary embolism.

(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales.
(2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes.
(3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care.
(4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales.