Milton Keynes University NHS Foundation Trust

4. Mrs A complains that on 12 April 2020 a Do Not Attempt CPR (DNACPR) order was added to her records without her consent. She also complains that on two occasions a commode was left in her room and the brakes were not applied. This led to a fall on the first occasion.

5. Mrs A tells us that discovering a DNACPR was on her records was distressing and she was angry that it was there without her approval. She also tells us the fall left her bruised and embarrassed.

6. Mrs A tells us she would like changes implemented at the Trust to ensure the matters she complained about do not happen to anyone else. She would also like assurance the DNACPR on her file is no longer valid and will not influence future care decisions.

7. Mrs A was admitted to the Trust on 7 April 2020 through the Accident and Emergency (A&E) department, after having fallen at home. She was admitted to a ward and, after recording a high temperature, was moved to a side room. It was while in this side room that she was visited by a doctor and the matter of a DNACPR was raised. This conversation took place on 12 April 2020.

8. The following day, when accessing the commode in the side room, Mrs A had a fall as the brakes on the commode were not locked on. This caused the commode to move, and she lost her balance and fell. Staff assisted her back to her feet.

9. On 14 April 2020, Mrs A was moved back to the ward and a commode was placed by her bed. She tells us that, due to her experience the previous day, she checked the brakes and found that once more they had not been locked on.

10. On 16 April 2020 Mrs A was discharged home from the Trust.

The DNACPR

12. Mrs A tells us she did not consent to the DNACPR but had insisted to the doctor that she would like to discuss it with her family first. The doctor’s recollection of the event is different, and during the Trust’s investigation they wrote that they had the discussion with Mrs A after their ward round and did obtain her consent. They also added a note to the records. They recalled a comment Mrs A made about her ‘not wanting people to start jumping on her chest’, though Mrs A recalls that she said this in repeating what the doctor had said.

13. We are therefore faced with a difference of opinion on the content and outcome of this conversation. We have no further evidence that would allow us to reach a robust decision about what was said and how it was said. We are unable to take a view on this aspect of the complaint, on the balance of probabilities, and as a result will take no further action on this particular issue.

14. However, we can give a view on Mrs A’s concerns that a DNACPR should not have been put in place without explicit consent. She tells us she continues to have concerns that having the DNACPR on record will influence any future decisions about her care.

15. The GMC guidance states that each individual should be assessed at the time of their treatment, as to the need for a DNRCPR. Except in certain emergency situations, when the question of a DNACPR should be discussed with the patient and/or family, dependent on the mental capacity of the patient at the time. However, the decision to put a DNACPR in place is ultimately taken by a medical professional and does not need a patient’s consent. NHS England and the Resuscitation Council UK provide helpful information to members of the public about why this is the case.

16. This means that while we know Mrs A was very anxious about the possibility of a DNACPR, there is nothing to suggest the Trust acted outside of applicable clinical guidelines in putting one in place without her explicit consent.

17. We have also thought about whether the Trust appropriately handled Mrs A’s concerns about the DNACPR remaining on her record. Our clinical adviser explained there are no standards or guidance on whether a DNACPR should be struck from the record if there is disagreement about whether it was consented to. The Trust also confirmed that, after speaking with Mrs A’s GP, it is confident there is no DNACPR in place in any of the community records, which it hoped would reassure Mrs A. The GP had advised the Trust they would also contact Mrs A and provide further reassurance. This is helpful and customer focused, and we are glad to see the Trust took this step.

18. The records show that the DNACPR validity period has ended, and that there are no outstanding DNACPRs on Mrs A’s medical records. The communication from the consultant, in the final response from the Trust, has explained this is the case.

19. As we have seen no indications of failings on the part of the Trust in this aspect of the complaint, we will take no further action on it.

Not securing the commode

20. We can fully appreciate that Mrs A was embarrassed to find herself needing help to rise from the floor and back to the commode. This is a very personal matter, and we know she found this experience very upsetting.

21. Section 8.5 of the NMC standards set out in the evidence section of this statement say that a nurse should ‘work with colleagues to preserve the safety of those receiving care’. Section 19.1 of the NMC standards also says that a nurse should ‘take measures to reduce as far as possible the likelihood of mistakes, near misses, harm….’

22. In this instance, the evidence shows that these standards were not met with regard to employing a commode in a safe manner. We think these are indications of failings by the Trust.

23. We have therefore considered the impact these errors caused to Mrs A and what the Trust has done to put things right.

24. We considered the records, and the Trust response to the incident, to see if it acted in line with the guidelines for reporting such incidents.

25. The Trust told us that when an incident occurs it is recorded on the Trust’s software for clinical and non-clinical incident reporting called Datix. These incidents can then be reviewed to determine if they meet the criteria for a serious incident, which has a reporting pathway both inside and outside the organisation. The Trust told us it also uses the information to help manage risk, and make improvements, to reduce the number of similar incidents.

26. We reviewed the evidence the Trust gave us and can confirm there is an entry in Datix for the incident that Mrs A describes on 13 April 2020, as well as an entry in the ward clinical records. This is in line with what we would expect to see.

27. We then considered the Trust’s response to the incident in its complaint response. It explained that a senior sister had investigated the complaint, confirmed the details had been entered onto Datix, and apologised that the commode had not been checked by a member of staff before making it available for use. They noted that apologies were offered at the time by the staff and the wider team were reminded about checking commodes.

28. This is in line with Section 14 of the NMC guidance, which says that a nurse should ‘act immediately to put right the situation if….an incident has happened which had the potential for harm. They should fully and promptly explain what happened and apologise to the person affected and where appropriate family or carers and document those vents formally’.

29. The senior sister apologised again that on a second occasion, the commode was left without the brakes on. They explained that Mrs A’s complaint had been shared with staff so they understood their expectations, regarding the safe use of commodes.

30. When we identify an organisation has made mistakes, we look at the impact those mistakes have caused and examine whether the actions taken by the organisation are enough to put things right. To help us, we refer to our Principles for Remedy, which say an appropriate range of remedies will include an apology, explanation, and acknowledgement of responsibility. We also considered our guidance on Financial Remedy, where we have our scale of injustice as a point of reference.

31. We understand, from speaking to Mrs A, that the impact caused by the Trust’s failure to put the brakes on the commode, was a short period of frustration and distress at the time of the fall and again at the time of the later near miss. Having considered the guidance above, we think that the actions the Trust has taken, have put this impact right for Mrs A.

32. We can see, in the complaint response, that the Trust has acknowledged responsibility for both incidents. It has taken action to attempt to prevent it happening in the future and provided an apology from both the senior sister and the chief executive.

33. This is in line with our Principles and, as a result, we will take no further action on this aspect of the complaint.

1. We have carefully considered Mrs A’s complaint about the Trust. While it was clearly very distressing for Mrs A to learn that a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) order was put in place without her consent, the evidence shows the Trust did not make any mistakes in doing so. Despite this, we are happy to be able to confirm to Mrs A that the DNACPR order is no longer valid, and will not be in place for any future care and treatment she may need.

2. We can also see from the evidence available that there are indications of failings in the provision of a commode on two occasions.

3. Having considered this in detail, we can see that while there are indications of failings in the staff provision of a commode, the Trust has already done enough to put right the distress and embarrassment this clearly caused Mrs A. We explain further below.