10. Mr O was admitted to the Trust on 18 February 2023, after experiencing prolonged diarrhoea and a mild kidney injury.
11. On 24 February Mr O was discharged home, after being transferred back to another hospital for rehabilitation. Mrs D says her father told her on 1 March that his discharge summary said he had a DNACPR notice while he was an inpatient at the Trust.
12. Mrs D says this was not discussed with her father or his family at the time. Mrs D also says when she contacted the Trust, it told her that it discussed the notice with Mr O. Mr O denies this. Mrs D says the DNACPR notice should never have been added to her father’s records and that doing this ignored his wishes, which were for resuscitation to be attempted if needed.
13. Mr O’s medical records show that on 18 February 2023, the day he was admitted to the Trust, an electronic DNACPR was completed for Mr O. This shows the decision was taken by the two doctors involved in Mr O’s care and was based on their assessment of Mr O’s frailty.
14. Mr O is recorded as being frail, at high risk of falls and needing a walking frame to get around. It is recorded that he had acute kidney disease (AKD) and both legs were swollen.
15. NHS England guidance on frailty includes a toolkit that says frailty is, ‘a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual's vulnerability for developing increased dependency and/or death’.
16. The plan noted on Mr O’s admission was to give him intravenous fluids (through the veins) and take more blood tests the next day. It is also noted he was not to be resuscitated. While no specific conversation with Mr O is noted, records show that at the time of his admission Mr O gave a description of his recent symptoms and operation.
17. The Trust says the DNACPR should have been discussed with Mr O and his family, to keep them fully informed. The Trust apologies this did not happen. It goes on to explain what resuscitation involves.
18. It added the chances of successful resuscitation were affected by not only the number of health conditions, but also the individual’s strength and physical reserve. The doctor assessed Mr O as his physical state meant the chance of survival with a good quality of life, was not high. The doctor also felt if Mr O did survive, he would be severely disabled.
19. The response confirms that a DNACPR form does not affect other parts of a patient’s treatment, as it would only apply if Mr O’s heart were to stop. The senior doctor is stated as feeling the decision was correct because to resuscitate would not benefit Mr O and could cause undue harm and suffering instead. The Trust goes on to recognise communication about the decision was poor and it apologised for this.
20. The Trust recognised its communication was poor and said the senior doctor involved in the decision has reflected on this and would discuss it with the junior doctors involved. The response also acknowledges it is important for both patients and their family to understand why the decision is being made. It apologises that Mrs D and her father felt the discussion should have involved the family members.
21. A Trust email dated 4 July 2023 tells Mrs D that if Mr O was readmitted to hospital, the DNACPR would be re-evaluated. It said to have the DNACPR notice removed from Mr O’s records she should contact the Subject Access Request Team. This was because requests to remove information from medical records falls under information governance and the complaints department cannot do this. The Trust also said there are strict national guidelines about the removal of information from medical records.
22. Mrs D’s email reply to this seems to refer to a phone call she had with the complaint officer who sent the email. Mrs O says the email does not reflect the conversation they had. She says during the conversation the complaint officer said the Trust apologised for the delay in replying and that the DNACPR had been removed and it wanted to meet her father.
23. On review of the evidence provided by Mrs D and the Trust, we cannot find any record of this conversation. It is not possible to confirm with any certainty what was said in this discussion.
24. In its response of 10 July 2023, the Trust says the senior doctor involved in Mr O’s DNACPR decision felt that Mr O had capacity to understand and he had explained the decision made by the clinical team. It adds that on reflection, the doctor accepts that Mr O’s capacity may have been inconsistent. This was because he was admitted with diarrhoea that had led to dehydration as well as a mild kidney injury, and this could have led to confusion.
25. Mr O’s records show assessments that suggest periods of confusion and times when he seemed to be fully aware of his circumstances. In an email from 12 June 2023, Mrs D stated her father had full capacity.
26. The Trust admits it would have been better to have discussed this matter with Mr O’s family as well as speaking with him. It also admits the part of the DNACPR form includes discussions with the family, that had not been filled in properly.
27. The Trust says this has been brought to the attention of the junior doctor who completed the DNACPR form. The senior doctor discussed this with them and they took important learning points from this to help with future practice.
28. This response apologies for how this experience affected Mr O’s faith in the Trust. It again reassures Mrs D that her father's electronic medical record does not have an active DNACPR status listed.
29. The Trust policy on cardiopulmonary resuscitation (CPR) says, ‘all patients admitted as an emergency should have a CPR decision recorded within 24 hours of admission recorded electronically’. Records show this requirement was met in Mr O’s case.
30. GMC professional standards on end of life care and decision-making say doctors must assess a patient’s capacity to make decisions. They also say doctors must work on the presumption that every adult patient has the capacity to make decisions about their care and treatment.
31. It goes on to say, ‘CPR is invasive, involving chest compressions, delivery of electric shocks from a defibrillator, injection of drugs, and ventilation of the lungs. If delivered promptly, CPR has a good success rate in some circumstances. Generally, however, CPR has a very low success rate and the burdens and risks of CPR include damage to internal organs and rib fractures, and adverse clinical outcomes for the patient such as hypoxic brain damage or increased physical disability. If CPR is not successful in restarting the heart or breathing, and in restoring circulation, it may mean that the patient dies in an undignified and traumatic manner.’
32. It adds that when considering whether to attempt CPR, doctors ‘should consider the benefits, burdens and risks of treatment that the patient may need if CPR results in the return of a spontaneous circulation.’ If the assessment is that treatment is unlikely to be clinically appropriate, they may decide that CPR should not be attempted.
33. Notes during his admission show Mr O was assessed as needing two people to help him when walking with his frame, as well as help with hygiene needs. It is noted he had fallen in late 2022 and had to swap his walking stick for a walker. He is noted as having episodes of confusion but is also noted as being aware of things like where he was, commenting on the wait for a bed and able to communicate his needs and allergy status.
34. We understand the distress Mr O and his family experienced when finding out about the DNACPR notice and they would like all record of this to be removed.
35. BMA guidance states, ‘Health records should not be altered or tampered with, other than to remove or correct inaccurate or misleading information’.
36. The Trust makes it clear in its response of 10 July 2023 that removal of the DNACPR record is not possible because this is a medical record based on the recollection of the medical staff involved at that time.
37. It reassures Mrs D that this is now a historical document and would not be used for future care. It apologised for using unclear wording when explaining the legal side of DNACPR decisions. It also confirms the decision to start or continue resuscitation is legally a medical treatment and it is a doctor's decision to make. This is in line with GMC guidance.
38. Mrs D states the Trust did not allow the complaint to be escalated in line with NHS Complaint Standards.
39. There are no signs the Trust stopped Mrs D from escalating her complaint. In line with NHS Complaints Standards, it told Mrs D she could bring her complaint to us if she was unhappy with the Trust’s handling of her complaint.
40. The Trust interacted with Mrs D whenever contacted it about her complaint and provided full, complete and sincere responses. It advised Mrs D how to make further contact with it and how to escalate her complaint to us. This is in line with NHS Complaint Standards.
41. It is our decision that the Trust has done enough to put right what went wrong and it is not reasonable for us to continue to investigate. We understand this will be disappointing to Mrs D and her family. We hope our explanation of how we have reached this decision is helpful.