Summary: The care provider was at fault in failing to ensure relevant information about the late Mrs X’s DNACPR status was given to paramedics: as a result, CPR was performed against her wishes. The consequence of that and of the care provider’s late response to the complaint has been considerable distress to her family.

The complaint

1. Mrs A (as I shall call her) complains the care provider carried out CPR on the late Mrs X even though there was a DNACPR decision in place. She says Mrs X declined in health rapidly after that and the family suffered considerable distress as a result of the incident.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

4. I considered the information provided to me by Mrs A and by the care provider. I spoke to Mrs A. The care provider and Mrs A both commented on my draft statement, and I took their comments into consideration before I reached a final decision.
5. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

Relevant law and guidance

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
7. Regulation 10 says service users must be treated with dignity and respect.
8. Regulation 11 says “Care and treatment of service users must only be provided with the consent of the relevant person.”
9. The CQC guidance on DNACPR instructions says, “Effective communication is essential. Decisions about CPR must be well made. They must be clearly understood by everyone involved…. Recorded decisions about CPR should accompany a patient. They should be accessible to those contributing to the patients care, when they move from one setting to another.”
10. Regulation 17 says “Records relating to the care and treatment of each person using the service must be kept and be fit for purpose.

Fit for purpose means they must:

Be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable. This includes results of diagnostic tests, correspondence and changes to care plans following medical advice.

Include an accurate record of all decisions taken in relation to care and treatment and make reference to discussions with people who use the service, their carers and those lawfully acting on their behalf. This includes consent records and advance decisions to refuse treatment. Consent records include when consent changes, why the person changed consent and alternatives offered.”

11. The care provider’s policy on CPR and DNACPR says, “Every decision about CPR will be made on the basis of a careful assessment of each resident’s situation.” It says, “If a DNACPR order is in place, the recognised Local Authority/GP/Trust form will be used to record and provide evidence of the decision.” It also says, “In the event that a resident goes into cardiac arrest, CPR will be performed unless there is a DNACPR in place. The DNACPR may be overridden if there is a clinical judgement, made by a suitably qualified person, that the cause of the resident’s respiratory or cardiac arrest is reversible and does not match the circumstances envisaged when the DNACPR decision was made and recorded.”

What happened

12. Mrs X went to live in the care home in November 2021. The care provider says during the pandemic, admissions were based on a “trusted assessor’s” referral form: in this case the form was sent to the care home by the local NHS trust. It was sparsely completed and left blank the section where a ‘yes/no’ answer was required to whether a DNACPR was in place.
13. The care provider subsequently completed a care plan after Mrs X was admitted. In the section about urgent care needs there was a tick in the box entitled “treat potentially life-threatening conditions early” but not in the “maximum active care” section. Mrs A says she personally delivered the DNACPR form to the care home office when Mrs X was admitted.
14. On 9 December Mrs X was found by a staff member lying on the floor of her room at 18.15. The daily care notes say there was a graze on the top of Mrs X’s head but “no other obvious injury”. Mrs X was lifted back on to her bed using the hoist. The notes record Mrs X became very agitated with slurred speech and unable to talk coherently: the nurse called 999. She noted the call handler said paramedics would be sent as soon as possible but, in the meantime, to observe Mrs X and if she lost consciousness, to put her in the recovery position and call 999 again. She called Mrs X’s daughter to keep her informed, and asked a carer to stay with Mrs X.
15. At 19.05 there was a change in shift. The nurse who came on duty said when she saw Mrs X she noticed her lips had turned blue and she was shaking. She called 999 again. The call handler asked the nurse to describe Mrs X’s breathing. The carer in the room took over the call as she says the nurse was not able to answer. She says she went and found Mrs X’s folder (later described as the yellow folder) with her details in to give a date of birth to the call handler. She says at no point did Mrs X’s breathing stop although it became rapid. She says the nurse began to carry out chest compressions as the call handler told her, although (the carer says) Mrs X had not stopped breathing.
16. The nurse says she telephoned Mrs X’s daughter to come in case Mrs X passed away with no family around her. Mrs X’s daughter says the situation was chaotic when she arrived.
17. When paramedics arrived they looked at the yellow folder containing Mrs X’s details and saw a DNACPR was in place. They stopped the nurse from continuing with chest compressions. Mrs X was admitted to hospital.

The safeguarding investigation

18. On 10 December the ambulance service raised a safeguarding alert with the county council. The alert raised concerns that even though Mrs X had a DNACPR in place the nurse was carrying out CPR on the advice of the call handler. It said the nurse was unable to give basic details about Mrs X’s conditions or medication and neglected to tell anyone that Mrs X had had a seizure.
19. The county council began a safeguarding enquiry. The care home manager confirmed to the council that there was a DNACPR in place for Mrs X and that she was in the process of interviewing staff about the incident.
20. The nurse on duty said in interview she did not look at Mrs X’s folder until the paramedics came and she did not know about the DNACPR. She said Mrs X’s daughter was in the room and could have stopped her. She said she realised now she should not have carried out CPR but as a nurse she felt it was her duty.
21. The safeguarding officer spoke to Mrs A who said the nurse had telephoned Mrs X’s daughter on her personal mobile on 7 January, while the nurse was off duty, and asked how Mrs X was. The safeguarding officer reported the matter to the care home manager as it was an unwarranted and unprofessional call, and implied relatives’ personal details were being taken off-site.
22. The safeguarding officer held a meeting with Mrs A and with Mrs X’s son and daughter. Mrs X’s family said the situation had been handled in a chaotic way. They said at one point there was the nurse, the senior carer and three fire officers in the room as the nurse had panicked and contacted the emergency response station behind the care home as well as calling 999.
23. The safeguarding officer obtained the call handler recording. She noted the absence of any question about the existence of a DNACPR, but also noted the call handler was having difficulties in controlling the call as the nurse and carer were giving conflicting responses (the carer said Mrs X was still breathing). She added that it was not a requirement for the question to be asked and that every emergency call had an individual set of circumstances.
24. The outcome of the investigation was that the concern was substantiated. The officer said, “it is clear that compressions were given by the nurse on shift when there was a DNAR in place. This accountability lays with the nurse irrespective of whether questions were asked by the call handler.”
25. The safeguarding officer discussed with the care home manager the requirements for training around DNACPR notices and the need for the notice to be put up in Mrs X’s room on her readmission for hospital.

The complaint

26. In January 2022 Mrs A made a formal complaint to the care provider on behalf of the family. She said the quality of Mrs X’s life had suffered immeasurably following the nurse’s decision to perform CPR despite the DNACPR in place. She said Mrs X had gone from being able to eat and drink independently and enjoy conversation to being totally dependent on others.
27. In May the care provider responded to the complaint. The manager who responded said Mrs X’s daughter had been present at the time CPR was performed. She said the nurse had been confused by the number of people in the room. She agreed the nurse should not have contacted the family after the event.
28. Mrs A was dissatisfied with the response to the complaint, especially the implication that Mrs X’s daughter (who she said was not present at the time) was in any way responsible for stopping the nurse performing CPR. She asked for the care provider to review the response to the complaint. She added that even after the incident, the family’s request for the DNACPR to be displayed openly in Mrs X’s room had not been met.
29. There was a significant delay before the care provider responded finally to the complaint. On 1 December the care provider’s Head of Care Quality wrote to Mrs A, apologising for the length of time taken.
30. The Head of Care Quality acknowledged that no blame should have been apportioned to any family member for the clinical actions of the nurse on duty. She said she had not been able to trace the original DNACPR document and the GP had confirmed they did not hold such a document for Mrs X. She said the hospital discharge notes confirmed that Mrs X had been admitted following a fall and seizure. She quoted the safeguarding report which said, “there is not any medical evidence to suggest the incident has impacted negatively on Mrs (X)’s health”.
31. The Head of Care Quality said the nurse in question was being supported to “enhance her knowledge and subsequent skill set”. She said it was disappointing that the request to display the DNACPR openly had not been met in a timely way: she said it was not the company policy to display confidential documents openly but there should have been a discussion with the family. She added that the home had a “robust system” in place to ensure team members were aware of the DNACPR status of each resident. Finally, she said that although the invoices for Mrs X’s care had been on hold during the investigation, the fees were now due.
32. Mrs A complained to the Ombudsman. She said the family had suffered considerable distress following the incident when they had watched Mrs X deteriorate. She said the care provider had showed a lack of compassion throughout. She also said the family should not have to pay the care fees which were only incurred because Mrs X’s life had been prolonged beyond its natural length.
33. The care provider says “Each individual has a room documentation folder and it is here that I have been informed that the reference/ actual DNAR was held. When completing my investigation I was unable to evidence that this document was in place at the time of the event.” It reiterates the statement from Mrs X’s GP that no DNACPR was held by the GP surgery.

Analysis

34. The nurse who came on duty when Mrs X was taken ill did not ensure she was aware of the DNACPR. She did not give the correct information to the emergency response call hander. That was fault which caused injustice to Mrs X and to her family.
35. Mrs X was not treated with dignity and respect by the nurse as the regulations require: instead there was an atmosphere described as ‘chaotic’ by Mrs X’s daughter and by the carer on duty. There is some suggestion the nurse was performing CPR even though Mrs X was still breathing. It was not until paramedics arrived that the existence of the DNACPR was noted and CPR stopped.
36. It was unhelpful, unkind and inappropriate of the care provider in its response to the complaint to question the existence of the DNACPR notice. It had clearly been found by the paramedics and the care home manager herself had told the safeguarding officer such a decision was in place.
37. It was also wrong of the care provider to imply, firstly, that Mrs X’s daughter was present when the nurse stated CPR and, secondly, that she shared any responsibility. The care provider later withdrew that suggestion, but it added to Mrs A’s impression that the care provider’s responses had lacked compassion throughout.
38. There was an unwarranted delay in ensuring the clear display of the DNACPR even after the incident, after the conclusion of the safeguarding investigation and after the complaint had been made. It was misguided of the care provider to say in its response to Mrs A that the care home had a “robust system” in place when that was not so.
39. The record keeping of the care provider was at fault: during the complaint investigation no-one could find the DNACPR which had been in place at the time of these events.
40. The safeguarding investigation substantiated the concerns raised by the paramedics.
41. There is no clear medical evidence to say it was the attempted CPR and not the fall and subsequent seizure which caused the sudden decline in Mrs X’s health; however, her family is left with the knowledge that CPR was performed against Mrs X’s wishes, and with the uncertainty of the outcome had the nurse acted differently.

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Agreed action

42. Within one month of my final decision the care provider will apologise formally to Mrs X’s family for the poor care provided to Mrs X on 9 December 2021, for the distress caused to them by its actions and for the delayed and inadequate responses to their complaints.
43. Mrs X has since died and so the injustice she suffered cannot now be remedied. Within one month of my final decision the care provider will make a payment of £1000 to her family in recognition of the distress caused by its actions. It will make an additional payment of £500 in recognition of the frustration caused by its late and inadequate response to the complaints.
44. Within one month of the complaint the care provider will set out for me details of the ways in which it has complied with the steps required by the safeguarding investigation.
45. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

46. I have completed the investigation and I find that the actions of the care provider caused injustice to the late Mrs X and her family, which the completion of the recommendations in paragraphs 42-44 will remedy.

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Investigator's decision on behalf of the Ombudsman