John Cook
PFD Report
All Responded
Ref: 2014-0578
All 1 response received
· Deadline: 4 Aug 2014
Coroner's Concerns (AI summary)
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.
View full coroner's concerns
(1) My concerns relate to the DNA CPR form coloured lilac. It is inevitable that queries will occasionally arise as to the validity of the form and related matters and by their very nature these are likely to be urgent. Although this particular Case Consultant who issued the form was reasonably clear there was no indication to which hospital or institution he worked for. It would be convenient if the name of the hospital were incorporated in the form, with a telephone number.
(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 recluded 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.
(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 recluded 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.
Responses
Disputed
NHS England will not add telephone numbers to DNA CPR forms, but highlights existing policy requiring specific review dates and clear cancellation procedures and has requested the CCG to share audit results and hold the Trust to account in relation to learning from the inquest; furthermore NHS England will write to all provider Trusts and CCGs to ensure they have adopted the DNACPR policy from NHS South of England. (AI summary)
NHS England will not add telephone numbers to DNA CPR forms, but highlights existing policy requiring specific review dates and clear cancellation procedures and has requested the CCG to share audit results and hold the Trust to account in relation to learning from the inquest; furthermore NHS England will write to all provider Trusts and CCGs to ensure they have adopted the DNACPR policy from NHS South of England. (AI summary)
View full response
Dear Mr Gardiner,
Re: Regulation 28 report – John Cook
Thank you for your letter dated 9th June outlining your matters of concern in relation to the above inquest. I have looked into both these concerns and please find below my response.
1. One of your concerns was the DNA CPR form and ensuring that it the name and the telephone number of the hospital is on the form. The form does have the institution name on it, however, it does not have the telephone number. It is our view that this is not necessary as the form is there to provide a clear definitive position, not to be something that prompts the need for further clarification through further phone calls. In addition to this telephone numbers change and the availability of particular clinicians may change. Therefore we will not be recommending there will be any changes made to the form.
2. The second concern was around the expiry date and cancellation of the DNA CPR form. The August 2012 NHS South of England (central) Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Adult Policy clearly states that the wording of “on discharge” is not acceptable, nor indeed the suggestion that the DNACPR ends just because of a discharge from hospital. The policy makes clear that if the DNACPR is not indefinite, then a specific review date should be inserted.
The issue in this case is that the existing policy was not followed. It clearly
Your Ref:
Thames Valley Jubilee House 5510 John Smith Drive Oxford Business Park South Cowley Oxford OX4 2LH
4/8/14
Mr N G Gardiner Assistant Coroner for Oxfordshire Oxfordshire Coroner’s Office The Oxford Register Office 2nd Floor 1, Tidmarsh Lane Oxford OX1 1NS
High quality care for all, now and for future generations states in the policy that in the rare circumstances where there is a decision made to cancel or revoke the decision, it should be clearly cancelled with two diagonal lines with the word “CANCELLED” written clearly between the lines, dated, signed and name printed by the health care staff member.
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.
NHS South of England as an organisation does no longer exist and therefore we will be writing to all our provider Trusts and CCGs to ensure they have adopted the DNACPR policy from NHS South of England for their own organisation.
I hope the above answers your concerns, please do not hesitate to get in touch if I can provide any further information.
Re: Regulation 28 report – John Cook
Thank you for your letter dated 9th June outlining your matters of concern in relation to the above inquest. I have looked into both these concerns and please find below my response.
1. One of your concerns was the DNA CPR form and ensuring that it the name and the telephone number of the hospital is on the form. The form does have the institution name on it, however, it does not have the telephone number. It is our view that this is not necessary as the form is there to provide a clear definitive position, not to be something that prompts the need for further clarification through further phone calls. In addition to this telephone numbers change and the availability of particular clinicians may change. Therefore we will not be recommending there will be any changes made to the form.
2. The second concern was around the expiry date and cancellation of the DNA CPR form. The August 2012 NHS South of England (central) Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Adult Policy clearly states that the wording of “on discharge” is not acceptable, nor indeed the suggestion that the DNACPR ends just because of a discharge from hospital. The policy makes clear that if the DNACPR is not indefinite, then a specific review date should be inserted.
The issue in this case is that the existing policy was not followed. It clearly
Your Ref:
Thames Valley Jubilee House 5510 John Smith Drive Oxford Business Park South Cowley Oxford OX4 2LH
4/8/14
Mr N G Gardiner Assistant Coroner for Oxfordshire Oxfordshire Coroner’s Office The Oxford Register Office 2nd Floor 1, Tidmarsh Lane Oxford OX1 1NS
High quality care for all, now and for future generations states in the policy that in the rare circumstances where there is a decision made to cancel or revoke the decision, it should be clearly cancelled with two diagonal lines with the word “CANCELLED” written clearly between the lines, dated, signed and name printed by the health care staff member.
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.
NHS South of England as an organisation does no longer exist and therefore we will be writing to all our provider Trusts and CCGs to ensure they have adopted the DNACPR policy from NHS South of England for their own organisation.
I hope the above answers your concerns, please do not hesitate to get in touch if I can provide any further information.
Sent To
- NHS England
Response Status
Linked responses
1 of 1
56-Day Deadline
4 Aug 2014
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 19 October 2012 I commenced an investigation into the death of John Cook aged
73. The investigation concluded at the end of the inquest on 29 May 2014. A copy of the Record of Inquest is attached. It will be seen that I returned a conclusion that He Died of Natural Causes.
The Cause of Death was given by Hunt at Inquest as: a Coronary Artery Thrombosis (and underlying Myocardial Fibrosis)
b Coronary Artery Atherosclerosis c Bilateral Pneumonia and Severe Cerebrovascular Disease
73. The investigation concluded at the end of the inquest on 29 May 2014. A copy of the Record of Inquest is attached. It will be seen that I returned a conclusion that He Died of Natural Causes.
The Cause of Death was given by Hunt at Inquest as: a Coronary Artery Thrombosis (and underlying Myocardial Fibrosis)
b Coronary Artery Atherosclerosis c Bilateral Pneumonia and Severe Cerebrovascular Disease
Circumstances of the Death
This 73 year old man was discharged from the John Radcliffe Hospital on 28 September 2012, and was receiving palliative care at The Manor Nursing Home, Bicester. He had been admitted to the John Radcliffe Hospital on 24 September 2012, with reduced responsiveness, a productive cough and reduced oral intake. The diagnosis was dehydration and hypernatremia. Active co-morbidities were noted to be vascular dementia, previous Cerebrovascular Accident together with sadly being bed bound and doubly incontinent. On 6 October 2012, Mr Cook was being cared for by staff at The Manor Nursing Home, when it was observed that Mr Cook was experiencing great difficulty in breathing and was deteriorating rapidly. Upon arrival of ambulance personnel, they discovered that Mr Cook was exhibiting Cheyne-Stokes respiration. At that time he was thought not to be for resuscitation, it was believed that a ‘Do Not Attempt Resuscitation’ (DNA CPR) form had been signed whilst in the John Radcliffe Hospital on 24 September 2012, the date of his admission. The ambulance personnel were asked to perform CPR on the instructions of the deceased's son. They did not comply with his wishes and Mr Cook was verified dead at 1820 on 6 October 2012 by the Thames Valley Police Medical Examiner. Subsequently it was found that the DNA CPR notice had expired on Mr Cook's discharge from hospital on 28 September.
Copies Sent To
Assistant Coroner for Oxfordshire
Dated
9 June 2014
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.