Implementing the DNAR
17. Miss B complains that, shortly after Mrs B’s admission, the Trust coerced her (Miss B) into agreeing to a DNAR without explaining why it was being put in place.
18. The DNAR form within Mrs B’s clinical records shows there was no record of a discussion with her but, given her presenting confusion, that was not surprising. Her presenting condition suggested that she likely lacked the capacity to make an informed decision herself and, due to this, a discussion with her Next of Kin was appropriate.
19. Our Physician Adviser explained that the DNAR Guidance is applicable here. Section 6.4 sets out communication and discussion with those close to a patient who lacks capacity. It states that, where the patient lacks capacity, any previously expressed wishes should be taken into account. It also states that relevant information should be shared with those who are close to the patient.
20. Our Physician Adviser also outlined how the Trust’s DNAR Policy also applies. It states that responsibility for a DNAR lies with the Consultant in charge with the patient’s care. It explains that in other circumstances a registrar who is either Specialist Trainee 3 (ST3) or Paediatrics and Maternity 4 can implement DNARs. Where a DNAR is implemented by someone other than the Consultant, then that Consultant must review the decision within, ideally, 24 hours.
21. The DNAR form within Mrs B’s clinical records says that a junior doctor held a discussion with Miss B. It is recorded that, during the discussion, Miss B said that Mrs B would not want to be resuscitated given her condition.
22. According to the Trust’s DNAR Policy, the junior doctor was not an appropriate level of seniority to implement the DNAR. As set out above, it should have been a doctor at the level of ST3 or above. However, ultimate responsibility for the DNAR lay with the Consultant in charge of Mrs B’s care who had a duty to review the decision within 24 hours.
23. We can see that the junior doctor signed the DNAR form at 13:45 on 2 June 2023. Whilst there is no time recorded on the form, we can see that the consultant in charge reviewed and signed the form later that same day. This was entirely appropriate and in line with both the DNAR Guidance and the Trust’s DNAR policy.
24. Our Physician Adviser also highlighted that the DNAR itself was not revoked at any stage during Mrs B’s admission. This adds weight to the fact that its implementation was entirely reasonable and in line with all relevant guidance and policy.
25. Miss B has explained that she was coerced into agreeing to the DNAR and that she was not happy with it at the time and the Trust implemented it regardless. We understand that this was an incredibly difficult situation and would have been undoubtedly stressful for both Miss B and her mother. We also know that she believes the conversation that took place was informal.
26. We were sorry to hear that Miss B felt coerced and did not realise the significance of the conversation about DNAR. The only available evidence to what happened are the two opposing recollections of events – the Trust’s perspective set out in the records and Miss B’s perspective that she was coerced. There is no evidence to tell us exactly why this misunderstanding occurred or how the doctor approached the conversation. It is more likely than not that, feeling DNAR was not in Mrs B’s best interests, this is what the doctor tried to convey to Miss B. This may have come across as pressuring to her whereas the doctor may have felt they were simply trying to present the suitability of the available options. We cannot say, even on balance, that Miss B was coerced but we do recognise that sadly, that is how she felt.
27. In summary, having considered the relevant evidence alongside the advice we have received we believe the Trust’s implementation of the DNAR was appropriate. Whilst the junior doctor lacked the necessary seniority to initially implement it, the decision was swiftly reviewed and signed off by someone who was. The record of the conversation shows that information was shared with Miss B and that Mrs B’s wishes, as recorded in the clinical records, were adhered to. This is all entirely in line with both the DNAR Guidance and, other than the junior doctor’s seniority, the Trust’s DNAR policy.
Feeding support
28. Miss B complains that staff failed to provide feeding support to Mrs B despite her not eating or drinking and losing weight during admission.
29. Our Nursing Adviser explained that the Nutrition Support Guidance was relevant here. Section 1.2 sets out the steps a Trust should follow to monitor nutrition levels and paragraph 1.2.6 clarifies the importance of accurate measurements. Specifically, the use of the Malnutrition Universal Screening Tool (MUST) which is a way to accurately determine BMI and is used to identify and manage malnutrition.
30. Paragraph 1.3.1 then sets out at what point nutrition support should be considered in people who are malnourished. In this context, it defines malnourishment as people who have any of the following: • A BMI of less than 18.5kg/m2 • Unintentional weight loss of greater than 10% within the last three to six months • A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last three to six months
31. Mrs B’s records show that her food and drink records were completed almost every day of her admission but indicate she was not eating an adequate amount. Whilst food and drink appears to have been offered throughout the day, Mrs B refused food on many occasions. We know that the food her mother was offered was a point of contention between Miss B and the Trust but is not something that we are looking at here. We can see in the records that home food is recorded as being provided on many of the days of Mrs B’s admission but it is not reliably documented how much was actually eaten.
32. It states through the notes that family were present continually and that they were feeding the patient food from home. There are several recorded occasions of Mrs B being offered hospital food that the family refused.
33. Having reviewed the fluid balance chart, we can see that it was consistently filled in. These records indicate that, although she was not drinking adequate fluids, IV fluids were supplementing Mrs B throughout admission. Her urine was also measured consistently and the rate did not indicate any evidence of dehydration.
34. To track her weight accurately, the Trust undertook weekly mid-arm circumference measurements and the records show that the results of these were stable. This indicates that Mrs B did not undergo any drastic weight loss during admission.
35. Essentially, our Nursing Adviser saw nothing within the records to suggest that Mrs B should have been considered malnourished. There were of course records showing she was not eating enough and that her fluid intake was inadequate as well. The Trust appears to have taken appropriate steps to both track and try to supplement these shortfalls. For eating, home food was allowed and documented where possible. For her fluids, these were again recorded consistently and IV fluids were provided to support her too. The Trust took reasonable steps to track her weight loss throughout admission.
36. Ultimately, there was nothing within the records to suggest that Mrs B was malnourished as defined within the Nutrition Support Guidance. Therefore, the steps staff took in order to support Mrs B during her admission were appropriate.
Mobilisation
37. Miss B complains that staff failed to mobilise Mrs B regularly.
38. Our Physician Adviser explained that NICE’s Patient Experience Guidance was applicable in this instance. It sets out that healthcare professionals should acknowledge the individuality of how each person experiences a condition and the impacts that condition has on their lives. It explains that it is important to recognise that individual patients are living with their condition, so the ways in which their family and broader life affect their health and care need to be taken into account.
39. Essentially, the Patient Experience Guidance dictates that no two people interact with a condition in the same way and it is important that the care provided by the healthcare professional takes this into account.
40. Our Nursing Adviser highlighted that, throughout Mrs B’s notes and especially in her repositioning charts, there was evidence she was being repositioned regularly. Beyond this, there are also multiple assessments completed by the Physiotherapy team during this time. The conclusion of those assessments was that Mrs B should only be mobilised, where possible, by being hoisted into a chair. The nurses on ward were therefore limited to the hoist and repositioning in terms of what mobilisation they could provide.
41. The records do set out that there were times when Mrs B was not mobilised but that these were not regular situations or for significant periods of time. There were also occasions that Mrs B was not mobilised for reasons outside of the Trust’s control – for example, on 21 June mobilisation did not take place as the records show Mrs B was tired and so the hoist was refused. Our Nursing Adviser explained that what the records showed was an acceptable number of mobilisations in line with the Patient Experience Guidance.
42. the evidence shows that Mrs B was mobilised regularly or mobilisation was attempted. Where those attempts failed, the reasons for why no mobilisation took place was documented. We appreciate why it felt to Miss B that not enough was being done. We hope our view helps assure here what happened was appropriate at the time.
Discharge
43. Miss B complains that the Trust discharged Mrs B inappropriately and in poor condition.
44. Our Physician Adviser explained that the Trust’s Discharge Policy outlined the process that should be followed. It clarifies that there are four clear discharge pathways beginning with Pathway 0 through to Pathway 3 increasing in severity depending on the patient’s condition. Pathway 1 applies to patients who are discharged with either new, additional, or a restarted package of support. This also relates to NHSE’s Principles, notably Principle 5 which covers the Home First approach – a principle that, where possible, patients should be supported to return to their home for assessment.
45. Mrs B’s condition, as set out within her clinical records, appeared appropriate for discharge according to our Physician Adviser. Her records showed that her white blood count was normal, her National Early Warning Score (NEWS) was 0, her potassium was recorded as normal, and her C-Reactive Protein (an indication of inflammation) was falling. She was assessed the day prior to discharge by the OT whose records show they were happy to discharge. She was also seen by the PT who recorded the necessary equipment had been sent to her home to aid with recovery.
46. The package of care the Trust implemented for post-discharge (four times daily) was, our Physician Adviser told us, the maximal package that would be provided by social care services in the community. This is alongside the equipment that had been issued to her home, The next step up would have been discharge to a rehab facility which would have meant the application of Pathway 3 rather than Pathway 2.
47. Our Physician Adviser highlighted that these points suggest the discharge decision was in line with Trust’s policy. Mrs B did not meet any of the criteria to reside that would have suggested a prolonged admission in hospital was required as opposed to an immediate discharge.
48. Mrs B’s records show that there was regular communication with the family, including Miss B. As well as this, the records set out that Miss B appeared keen to see Mrs B discharged home and that she was ultimately satisfied with the decision to discharge her mother and the plan the Trust had put in place.
49. In line with the evidence we have considered and the advice we have received, we believe the decision to discharge Mrs B was appropriate. The Trust applied its own Discharge Policy reasonably with the level of care it put in place post-discharge for Mrs B. Whilst Mrs B was only discharged home for a few days before being admitted to another Trust, that does not mean that the Trust’s decision was incorrect. Her records suggest that she was in a suitable condition to be discharged home with the additional support it had arranged in place.
50. We were sorry to hear of Mrs B’s condition and the fact that it necessitated a further hospital admission only three days after her discharge. We understand that she remained there for a number of months but that she has made recovery progress since that time. It is clear from the records and from speaking with Miss B that her mother’s admission was and continues to be a difficult experience for her entire family.