DNAR notice added to notes
9. Cardiopulmonary resuscitation is a treatment that for some people may restart their heart when they suffer an unexpected cardiac arrest. In many people with chronic disease, this treatment is relatively unlikely to be successful. The Resuscitation Guidance explains there are cases in which trying to resuscitate a person could do harm, and that it is better to have a decision about whether to try resuscitation beforehand. A decision not to attempt resuscitation is usually recorded as a DNAR.
10. The Trust added a DNAR to Mr U’s records. Mrs U says that, given his recent diagnosis of dementia, the Trust should have told her and involved her in the decision-making.
11. The Trust says Mr U had the ability to make the decision himself. The records show Mr U agreed with the decision and added a comment to the form to say, ‘I’ve had a good life, wouldn’t bother’.
12. We talked about the guidelines with our adviser. We referred to the Resuscitation Guidance. We needed to see whether or not Mr U lacked the ability (capacity) to sign and agree to the DNAR form, and whether or not Mrs U should have been told about this decision by the Trust.
13. The Resuscitation Guidance says:
‘Even when CPR has no realistic prospect of success, there must be a presumption in favour of explaining the need and basis for a DNACPR decision to a patient, or to those close to a patient who lacks capacity. It is not necessary to obtain the consent of a patient or of those close to a patient to a decision not to attempt CPR that has no realistic prospect of success. The patient and those close to the patient do not have a right to demand treatment that is clinically inappropriate and healthcare professionals have no obligation to offer or deliver such treatment.’
14. Our adviser told us that to make a formal decision about whether or not a person has capacity would need the completion of a mental capacity form. There is no evidence the Trust carried out this assessment on the day it filled in the DNAR form with Mr U.
15. However, the Trust did carry out a capacity assessment four days later. The form shows doctors knew Mr U had been diagnosed with dementia. This form shows the following:
1. Does the person understand the information relevant to the decision? – Yes 2. Is the patient able to remember the information long enough to make the decision? – Yes 3. Is the patient able to understand the importance of making the decision? – Yes 4. Is the patient able to make their decision clear either by speech, sign language or by any other means? – Yes
16. As the answer to each of those questions was yes, the Trust showed Mr U did not lack capacity to make the decision on his own.
17. Mr U was in the early stages of dementia. We have seen nothing to show that his level of capacity would have been very different four days earlier.
18. The DNAR form shows the Trust did talk about the DNAR with Mr U. It shows his comments about it. Those comments show he was aware of what he was signing.
19. We have seen nothing to show Mr U did not have the capacity to understand what he was talking about and agreeing to when doctors talked to him about DNAR. While he was in the early stages of dementia, which is what Mrs U is worried about, the test four days later shows it was not causing a problem for his mental capacity for decision-making.
20. As we have seen no evidence Mr U lacked capacity when he agreed to the DNAR, there are no signs of failings in the Trust's decision to talk about it only with him as stated in the Resuscitation Guidance. We can understand why Mrs U believes she should have been involved in this discussion, but the Resuscitation Guidance does not say this is needed where a patient has capacity to make their own decisions.
Delays in blood tests and medication
21. Mrs U says the Trust failed to carry out relevant blood tests before Mr U’s death. She says delays in tests and their results had a knock-on effect on Mr U getting medication too late to give him the treatment he needed, especially for his raised potassium levels.
22. The Trust accepted there were delays in finishing Mr U’s blood test on 31 August 2021. The Trust also accepted that the delay meant it was unaware his potassium levels had gone up until the registrar checked them in early September.
23. We do not need to think in detail about whether there were any delays in the Trust carrying out the blood tests. It has already accepted there were. The Trust also accepted there were delays in giving Mr U intravenous sodium bicarbonate (a treatment for high potassium) as it was not available on the ward.
24. Mr U’s death was due to fibrinous pericarditis (infection of the protective sac around the heart) and tamponade (when the fluid sac around your heart fills with blood or other fluid, putting pressure on your heart).
25. Our adviser said that earlier treatment with sodium bicarbonate would not have made any difference to the sad outcome for Mr U. Sodium bicarbonate is used to reduce the effects of metabolic acidosis (the build-up of acid in the body), which makes the effects of high potassium worse, but it is not a treatment for pericarditis or tamponade. We have therefore seen no signs the delays had an impact on Mr U’s chances of survival.
26. Mrs U feels the Trust have not taken her concerns seriously, and that it has ‘fobbed her off’ with its response.
27. We have seen no signs this is the case. The Trust has itself found the delays in doing the blood tests and giving Mr U the correct treatment of sodium bicarbonate. The Trust has shown it has taken this incident seriously. Its incident report accepts that it fell short of carrying out the tests and reviewing results quickly enough.
28. The Trust also made recommendations for the ward in question, and to be shared across the Trust. This learning was to make sure that blood tests are carried out on time and, importantly, to make sure staff knew how to get hold of sodium bicarbonate when this is not available on a ward.
29. Mrs U wants to see that this will not happen to other people. While we can never guarantee this will be the case, the Trust has taken positive steps to lower the risk of this happening in future.
30. Our ‘Principles for Remedy’ say that where maladministration (a fault) or poor service has led to some kind of failing, public bodies should try to make things right in a way that returns the complainant to the state they would have been in otherwise. If that is not possible, they should compensate them appropriately. There are no automatic or routine ways of doing this. The response can include an apology, explanation, acceptance of responsibility and improvements to services.
31. The Trust has made an apology for what happened with Mr U’s treatment, and it has made a plan to put things right, accepting its responsibility to give better treatment. We think this apology and action plan are enough to put the failing Mrs U experienced right. This is what Mrs U wanted when she brought the complaint to us. We have seen no signs that further action is needed.
Call to Mrs U after Mr U’s death
32. Mrs U says the Trust did not tell her of her husband’s death until six hours after his death. The Trust’s records say it did try to call her, but it was unable to get in touch with her.
33. The GMC Guidelines say doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
34. There seem to be two different versions of what happened when the Trust called Mrs U. On the one hand, we have the Trust saying it tried to call her without success during the night, and on the other we have Mrs U’s version, which says the first time it tried to call her was six hours later.
35. While we have no reason to doubt Mrs U’s version of events, it does not match the Trust’s version of events. Even if we looked into this in detail, we do not have enough evidence to say the Trust did not try to get in touch with Mrs U sooner than it finally reached her. That is not to say we do not believe what Mrs U says, but we would not be able to make an evidence-based decision either way. We will therefore take no further action on this part of her complaint.
36. We are grateful to Mrs U for taking time to tell us about her complaint. We know this cannot have been easy for her.