North Cumbria Integrated Care NHS Foundation Trust

4. Mr A complains about the care and treatment the Trust provided to his father, when staff admitted him to the Trust in April 2025 with heart issues. Mr A specifically complains the Trust completed a DNACPR form without his family’s knowledge and did not communicate this correctly, in line with the Trust’s guidelines and policy.

5. As a result, Mr A says:

• his family experienced unnecessary stress and anxiety • they lost confidence in the Trust and its ability to provide future care for his father.

6. Mr A is seeking the Trust to understand the impact its actions had on his family, an investigation into the culture of the Trust and for the Trust to show his family genuine respect.

7. In April 2025, the Trust admitted Mr A’s father to its Critical Care Unit, with symptoms of a racing heart.

8. During his father’s admission, a consultant at the Trust completed a DNACPR form without consulting Mr A and his family.

9. They discussed the DNACPR order with Mr A’s father.

10. Nine days after admitting him to hospital, the Trust’s staff discharged Mr A’s father. They gave his family his discharge paperwork, which included his DNACPR information. It was at this point Mr A and his family became aware of the Trust’s decision about resuscitation.

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. Having done so, we have found the Trust has already done enough to put right the impact of the events Mr A complains about.

14. Although staff did not make Mr A aware of his father’s DNACPR order at the time, he told us he discussed it with a consultant at the Trust on 27 June 2025.His family agreed to the DNACPR order being in place.

15. In its complaint process, the Trust apologised for its lack of communication regarding the DNACPR order it completed for Mr A’s father.

16. The Trust explained that on review, Mr A’s experience demonstrated several points which the clinical team at the Trust could learn from regarding communicating DNACPR orders.

17. The Trust say it is evident from the medical records Mr A’s family made several attempts to discuss the decision of the DNACPR order and request a second opinion. The Trust apologised the family did not receive a response to their request in a timely manner.

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19. We can also see the Trust’s response identified a discussion with Mr A’s family about resuscitation did not take place at the time staff decided on the DNACPR order. The Trust said this should have happened.

20. The Trust say that although this would not have altered the DNACPR decision, it understood this would have allowed Mr A’s family the opportunity to ask questions and be part of the decision-making process.

21. The Trust apologised for the additional stress and anxiety this omission caused Mr A’s family. We agree the Trust’s lack communication here caused this stress and anxiety.

22. We can see from the Trust’s response it recognised the need for the staff involved to reflect on the concerns Mr A raised. This was with a view to ensure they communicated better in the future, and they understood the importance of a better patient and family experience in difficult circumstances.

23. When we see indications something has gone wrong, we look to see if the organisation has done enough to put things right. Our principles say the public body should ensure the complainant receives:

• an acknowledgment about what went wrong and the injustice or hardship this caused • an assurance that lessons have been learnt • an explanation of changes made to prevent poor service being repeated.

24. The Trust’s response has acknowledged staff should have done things differently. They should have involved Mr A’s family in the decision and communicated its decision about his father’s DNACPR order. It also recognised the impact this omission had on Mr A and his family, and it apologised about this.

25. We can see that the Trust has raised this with the staff involved, for their reflection and to ensure better communication with families in the future.

26. This means the Trust has acted in line with our principles and already provided the outcomes Mr A seeks. Therefore, we do not see the Trust should take further action to put things right in relation to Mr A’s concerns.

27. We understand this has been a stressful and difficult situation for Mr A and his family, and we appreciate his efforts in bringing his concerns to our attention. We hope we have clearly explained why we have decided to take no further action.

1. We have carefully considered Mr A’s complaint about North Cumbria Integrated Care NHS Foundation Trust (the Trust).

2. We are sorry to hear the distress Mr A and his family experienced, following a do not attempt cardiopulmonary resuscitation (DNACPR) decision made for his father by the Trust.

3. We saw the Trust should have communicated about the DNACPR order with Mr A’s family and did not. We have decided the Trust has already done enough to put right the impact of these events on Mr A and his family.