DNACPR
13. Mr and Miss U say Trust staff decided that Mr O should not be resuscitated if his heart stopped and placed a DNACPR in his notes. They say staff made this decision against the family’s wishes and it was against Mr O’s religious beliefs.
14. We are sorry to hear this caused the family distress and Mr and Miss U feel their father’s religious beliefs were not carried out.
15. In its complaint response dated 13 March 2023, the Trust said a decision not to resuscitate is always done in a patient’s best interest. It said, whilst it is good practice to keep the family informed about a DNACPR decision, it is ultimately not the family’s decision. The Trust said staff followed guidelines and several doctors made the decision in Mr O’s best interests and any attempts to resuscitate would prolong his suffering.
16. NHS guidance ‘Do not attempt cardiopulmonary resuscitation (DNACPR) decision’ says ‘DNACPR is a medical treatment decision that can be made by your doctor even if you do not agree. You must be told that a DNACPR form will be/has been completed for you, but a doctor does not need your consent.’
17. GMC’s ‘Treatment and care towards the end of life: good practice and decision making’ says: ‘If the legal proxy [in this case the family] requests that CPR is attempted in future, in spite of the burdens and risks, or they are sure that this is what the patient would want, and it is [a doctor’s] considered judgement that CPR would not be clinically appropriate for the patient, [doctors] must sensitively explore the reasons for the proxy’s request, their understanding of what it would involve, and their expectations about the likely outcome. If after further discussion [a doctor] still consider that attempting CPR would not be clinically appropriate for the patient, there is no obligation to provide it in the circumstances envisaged. [A doctor] should explain [their] reasons and any other options that may be available to the legal proxy, including their right to seek a second opinion.’
18. Our adviser said CPR can work if a patient is otherwise well. Mr O had a history of tuberculosis, had fluid on his lungs in 2004 and had to use two walking sticks. The clinical notes show he had advanced COVID-19 pneumonitis at the time doctors made the DNACPR decision and was unresponsive. Trust staff had treated Mr O with high flow oxygen by a non-invasive ventilation (NIV – a pressure mask), steroids, antibiotics and anti-viral medication.
19. Our adviser said if this treatment could not prevent Mr O’s heart stopping, CPR would not have helped. They said CPR does not necessarily mean a person will live any longer and if they only survive for a short period, it is likely the person will suffer more harm. As such CPR would not be in their best interests, as outlined in the GMC guidance.
20. The evidence shows the consultant who completed and signed the Recommended Summary plan for Emergency Care and Treatment (ReSPECT) form, and therefore made the DNACPR decision based this on their clinical judgement. Miss U asked for a second opinion and the consultant sought this. The Intensive Care Unit doctor and consultant both agreed with the DNACPR decision. Our adviser said, based on the evidence, they would have made the same decision in the circumstances.
21. The evidence shows doctors discussed the DNACPR decision with the family and explained this to them. This was because Mr O himself was not conscious. Our adviser said whilst the wishes and religious beliefs of the family can be considered, this does not affect the clinical decision and the doctors did not need Mr O’s or his family’s consent to do this. Taking all this into account, it appears the Trust doctors made this clinical decision in line with GMC and NHS guidance.
22. For these reasons, we have not seen any indication the Trust did anything wrong in relation to its DNACPR decision and we have decided not to investigate this further.
Information sharing and updates
23. Mr and Miss U say staff communication was poor and inadequate. They say there was a lack of information and updates about their father’s condition. We are sorry to hear this caused the family to feel confused and uninformed.
24. In response, the Trust said the records show that staff provided the family with very good levels and amounts of communication to keep them updated on Mr O’s condition.
25. GMC’s guidance ‘Confidentiality: good practice in handling patient information’ says doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support, while respecting the patient’s right to confidentiality.’ It says, ‘You might need to share personal information with a patient’s relatives, friends or carers to enable you to assess the overall benefit to the patient. But that does not mean they have a general right of access to the patient’s records’.
26. In relation to patient’s who lack capacity, as in Mr O’s case, the guidance says doctors ‘may disclose personal information if it is of overall benefit to patient who lacks the capacity to consent. When making the decision about whether to disclose information about a patient who lacks capacity to consent, [doctors] must make the care of the patient [their] first concern.’
27. There are extensive clinical notes which document regular and often lengthy discussions where staff updated the family. The notes show a doctor gave a detailed update on the evening of 7 January 2022, the day Mr O was admitted. An entry at 2.06pm on 8 January says a doctor spent two hours discussing Mr O’s condition with his family. The notes continue to show that doctors and nurses updated the family daily, until Mr O sadly passed away on 21 January. Our adviser said they consider the updates recorded in the clinical notes were regular and comprehensive and in line with GMC guidance.
28. Our adviser said it is understandable that family members want to be informed about their relatives’ care but this does not mean they should expect to be informed of every detail, as outlined in the guidance.
29. Considering guidance says patient care is the primary concern and that this was during a time when NHS resources were under significant pressure because of COVID-19, the notes show Trust staff spent a great deal of time with the family and provided regular and detailed updates.
30. For these reasons, we have decided not to investigate this further.
Staff behaviour
31. Mr and Miss U say staff were rude, obstructive and unprofessional towards the family.
32. Miss U says a doctor and a healthcare assistant (HCA) made inappropriate comments when she disputed the DNACPR decision on 10 January 2022. Miss U is Muslim and she told us, from the staff comments, she believes the doctor and HCA were Muslim also. She says they responded to her indicating a conflict in religious beliefs.
33. We are sorry to hear that Miss U was shocked and offended by the comments.
34. In the Trust response, it said the notes show staff had said that resuscitation attempts would add to Mr O’s suffering and that his soul would not be at peace. It said the notes show staff retracted the comments and the family accepted this. In its response, the Trust apologised for the distress and upset the statement caused.
35. Our principles say organisations should acknowledge mistakes and apologise where appropriate.
36. The clinical notes document the conversation and show a member of staff said resuscitation would add to Mr O’s suffering and his soul would not be at peace. The notes go on to say Mr O’s daughter was offended by the comments so the staff member retracted the comments and the daughter accepted that.
37. In our conversations with Miss U, she confirmed the doctor and HCA apologised after the conversation had taken place.
38. In its complaint response, the Trust has since apologised for the distress and upset this caused.
39. As an outcome to their complaint, Mr and Miss U want the Trust to acknowledge what went wrong and to apologise. In line with our principles, we consider the Trust has done enough to put this right by staff apologising at the time, the Trust later acknowledging the comments caused distress and apologising for this. As such, we will not be investigating this further.
40. Mr and Miss U say staff were intrusive, obstructive and rude towards the family when visiting. They say this includes that staff asked family members for their names, went behind closed curtains when family were visiting, were rude when family asked questions and wrote inappropriate comments in medical notes. They say staff wrote several comments that the family were aggressive, rude. They say, by writing this in the notes, staff were being aggressive and discriminatory.
41. We are sorry to hear the events caused upset to the family at an already difficult time.
42. In response, the Trust said it found the medical records are as expected and that staff found it difficult to meet family expectations under difficult circumstances. It said it is good practice for staff to take names of visitors and to check on families when curtains are drawn. The Trust reiterated that staff spent a great deal of time with the family and it understands the family found some of the conversations difficult. It said that staff had documented that they had also found discussions with the family difficult and challenging due to the approach of the family at times.
43. The Trust also said the notes show an entry about an incident on the ward on 19 January where a family member had gained access to the ward without permission and they were asked to wait in the relatives’ room. The Trust said the notes show the family member had to be escorted from the ward and called security.
44. GMC’s, ‘Good Medical Practice’, says the records doctors make must be clear accurate and legible. It also says clinical records should include clinical findings and information given to patients. NMC’s, ‘The Code’ says nurses should keep clear and accurate relevant to their practice.
45. NMC’s ‘The Code’ also says nurses must ‘identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need’.
46. Our adviser said, if staff feel a patient, family member or visitor behaved inappropriately, they have an obligation to write this in line with NMC and GMC standards. They said on handover or when using notes in patient care, staff need to be aware if there are any concerns about relatives. This is so future staff can plan for communication with family. They went on to say if staff are aware of this, they can plan to take somebody with them or allow more time to explain things. The staff have a right to an opinion and to write this down if this is done professionally, and we consider it was in this case.
47. Our adviser said most hospitals will only allow one or two patients to visit at a time. This was stricter during the COVID-19 pandemic.
48. The Trust’s, ‘COVID-19 Pandemic Interim Visiting Policy’, outlines a safe approach to visiting during COVID-19. This policy says general adult inpatient visiting was suspended at the time Mr O was in hospital. It goes on to say compassionate visiting can be allowed for those patients at end-of-life. It says in these cases, patients may require more than one visitor to be managed on an individual basis. It also says staff will consider a risk assessment of each visitor. Appendix B of the policy shows this involves taking visitors’ names.
49. Our adviser said, whilst there are no specific guidelines, even outside of COVID-19 restrictions it would be normal practice for staff to approach anybody who goes onto a ward to ask who they are, for security and safety reasons. They said staff are supposed to identify visitors because a hospital ward is a sensitive environment where security and confidentiality are important for patients, staff, and visitors. This is the reason each ward has a security door and visitors need to be buzzed in. They said it is also important for staff to know who to direct doctors to, if they need to speak to them.
50. Our adviser went on to say, whilst there are no specific guidelines around this, it would be normal practice to check on a patient and visitors when curtains are closed. They said it is important for staff to check on any needs of the patient or visitors.
51. For these reasons, we have not seen any indication Trust staff did anything wrong by asking family members for their names, checking behind closed curtains when family were visiting, or recording their comments in medical notes. We consider staff acted in line with GMC and NMC guidance in relation to these actions.
52. For these reasons, we will not be investigating these parts of their complaint further.
53. We have considered Mr and Miss U’s complaint that staff were generally bad tempered and that a nurse made inappropriate comments within hearing of their mother.
54. In its response, the Trust acknowledged the family felt communication could have been better and apologised for the distress caused.
55. We appreciate this was a difficult time for the family and the evidence suggests the relationships with staff were strained. We understand this was an already upsetting time for the family as Mr O was so poorly. We also understand this was a demanding time for staff.
56. We make our decisions based on evidence. In relation to this part of Mr and Miss U’s complaint, we did not witness the events for ourselves, there is no other record of these issues and we have decided we cannot reach a view based on the evidence we have.
57. For this reason, we have decided not to investigate this further.
58. We are sorry the issues Mr and Miss U have brought to us caused them upset and had a negative impact on their mental wellbeing. We are grateful to them for telling us about their experience which we appreciate was a very difficult time for them. We hope they are reassured by what we have seen.