Cheshire East Council at fault for not having a process for reviewing Do Not Attempt Resuscitation (DNAR) documents in place

Decision Date: 1st February 2021

What Happened

Ms E complained on behalf of her late mother, Mrs F. 

Mrs F was a resident at Ingersley Court Residential Care Home. The Council arranged and partly funded her care.

On an undisclosed date, Mrs F complained to her carer that she felt sick at 7pm. The carer reported this to the team leader on duty. 

Mrs F still felt ill when she was checked on at 10:15pm. 

At 10:47pm Mrs F’s stomach felt worse, and she felt cold and clammy. Her carer stayed with her. 

At 11:15pm the carer called for an ambulance. (the report did not go into Mrs F’s symptoms at this point).  Around midnight when the paramedics arrived, they asked whether Mrs F had a ‘do not attempt resuscitation’ (DNAR) decision on file. 

The carer could not find a DNAR in Mrs F’s file, so called Ms E to inform her of Mrs F’s condition and ask about a DNAR decision. 

Ms E said that there was a DNAR on file, but since it could not be located the paramedics began resuscitation. 

Mrs F unfortunately passed away. 

Ms E complained that the care home took too long to call for an ambulance or herself to be informed of her mother’s condition. She also complained about the DNAR missing from Mrs F’s file, and finally about the state of Mrs F’s room when the family visited the next day. 

The care home stated Mrs F did not have a DNAR decision in place, the carer had called the ambulance at an appropriate time and contacted Ms E as soon as she could. It apologised for Mrs F’s room not being cleaned after she died and that in the future domestic staff would be instructed to ensure this did not happen again. 

Ms E was unhappy with this response and asked for a review. After its review, the care home maintained that it called for an ambulance at the right time, and apologised again for the unclean room. 

The Council also investigated Ms E’s complaint at this time. It stated: 

  • The carers could not call the family sooner as they were trying to manage an emergency;
  • The carers called for an ambulance when they saw Mrs F’s condition was deteriorating;
  • The care home manager spoke with Mrs F’s GP and the GP did not have a record of a DNAR decision;
  • The Council recommended the care home reviewed its DNAR records regularly, clearly recording the wishes of a resident to avoid contacting families in an emergency;
  • The state of Mrs F’s room was unacceptable, and the care home had reflected on how it should have agreed a mutual time when it knew the room was satisfactory for family members to attend.

Ms E remained unhappy with the Council’s response and complained to the LGO. 

What was found

The LGO stated that although Mrs F first reported feeling unwell at 7pm, and an ambulance was not called for until 11:15pm, the staff acted appropriately. When the staff began to have serious concerns, they promptly called for the ambulance. The team leader on duty waited with Mrs F until the paramedics arrived. The care home’s policy stated that if there were ever concerns regarding the health of their residents that the staff cannot manage, emergency services should be contacted. Therefore the care home acted in accordance with its policy and there was no fault in this regard. 

There was also no fault in the amount of time it took for the care home to contact Ms E to alert her to the situation. The LGO agreed with the Council in that the staff acted in Mrs F’s best interest. They were managing and prioritising an emergency situation, and the LGO was satisfied that Ms E was called at the safest opportunity. 

Ms E said that Mrs F did have a DNAR in place. During its investigations the LGO could find no record of this. However, the LGO did identify that the care home did not have a process to regularly review its DNAR records (to avoid contacting family in an emergency). This was fault. The care home informed the LGO that it has since implemented a review process. 

The LGO recommended that the Council:

  • Apologise to Ms E for the upset and distress caused by failing to have a proper process in place to review the DNAR documentation
  • Pay Ms E £300.

Points to note for councils, professionals, people who use services and their carers, advocacy providers, members of the public

Those reading will note that the Council was found at fault in this complaint, albeit for the actions of the care home (here, omissions) as it remains responsible for those services provided to meet an individual’s needs.  The LGO can investigate complaints about bodies providing services on behalf of a Council and in this case was able to consider whether the actions of the care home should be found as fault. 

The issue that arose in this situation was that of a DNAR recording policy. DNAR rules were widely ignored during Covid by GPs and care home managers being told what to do BY GPs, but here the issue was that there was actually supposed to BE one, which could not be found, which meant that someone who may well have indicated that she did not want to be resuscitated, was put through the pain and indignity of an attempt being made. Ms E was called in an emergency and had clearly believed that the appropriate documentation of a DNAR was in place and that the process had all been gone through beforehand. This must have been a shock to her and she wouldn’t have been expecting such a call. 

The LGO was not able to find any documentation supporting Ms E’s position, and clarity would have been obtained sooner had the home been commissioned to do its job properly, or had thought to do it properly, for itself.  

Guidance from the British Medical Association, Resuscitation Council UK and Royal College of Nursing can be found on the link below and states this:

Decisions relating to CPR must be documented fully and clearly in both electronic and paper records. Healthcare providers using electronic records should have systems in place to ensure that decisions relating to CPR are available as soon as they are required. The format and content of an electronic CPR decision form should be similar to that of a paper CPR decision form’. 

https://www.bma.org.uk/media/1816/bma-decisions-relating-to-cpr-2016.pdf

The LGO recommended a financial payment to be made by the Council in respect of the distress caused by the situation. So although the LGO does not have the ability to ‘correct’ such errors and omissions, Councils should expect their contract monitoring staff to learn from these complaints and embed improved practice measures. When CQC starts to review councils’ commissioning practices under the Health and Care Bill it will be interesting to see what CQC takes from LGO reports such as this, assuming that commissioning for individuals is within its inspection purview (unclear as yet).

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The full Local Government Ombudsman report of Cheshire East Council’s actions can be found here

https://www.lgo.org.uk/decisions/adult-care-services/residential-care/19-018-012

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