The coroner for Exeter and Greater Devon, Dr Elizabeth Earland, has called for greater clarity and communication following what she described as a 'disturbing case' concerning Do Not Attempt Resuscitation (DNAR or DNR) orders.
The calls came after an inquest into the death of 86 year old dementia patient Mrs Jean Robson who developed pneumonia and spent several days in the Royal Devon and Exeter Hospital but died in a care home. Hospital staff gave her fluids and foods, but felt there should be no overt intervention in her treatment after consultation with her daughter Dorothy, who worked as a nurse for 20 years.
Dorothy Robson explained to hospital staff that, before becoming ill, her mother had clearly stated she did not want her life extended beyond what was felt to be reasonable. Consequently a Do Not Attempt Resuscitation order was placed in Jean’s notes. At her daughter’s request, Mrs Robson was moved back to the familiar and comforting environment of the nursing home for her final few days, but the DNAR order or the wishes of the family was not communicated to the staff at the home.
Consequently, when Mrs Robson suffered a choking incident, staff at the home responded as you would expect them to by calling 999. Jean died amid what was described as a ‘distressing altercation’ between her daughter two nurses at the home and paramedics who attended the scene. The discharge summary from the Royal Devon and Exeter Hospital did not contain specific reference to Mrs Robson's Do Not Resuscitate status whilst she was in hospital, but in any event, the DNR order could not have been used to withhold treatment in a community setting.
Do Not Attempt Resuscitation orders generally refer to not resuscitating a patient only if their heart stops. The fact that Mrs Robson died following an acute choking incident must have been very distressing for her and her family, but equally so for nursing care home professionals and ambulance staff who were in the invidious position of being prevented from doing what they felt bound to do by a general lack of understanding of the remit of the DNAR order.
The coroner said it was ‘concerning’ the hospital had not made the home aware of the DNR order and criticised what she called a ‘lack of clarity’ about the remit of DNAR orders. Dr Earland issued a coroner's letter to bodies including the Department of Health, the Care Quality Commission and the Royal Devon and Exeter Hospital raising those concerns, to which notified organisations have a statutory duty to respond within 56 days.
The coroner made no criticism of the care home, whose staff responded ‘appropriately’ to an apparent need for medical intervention but the inquest did highlight some confusion about DNR orders and how they are used.
Andrea Rusbridge, a partner in Shoosmiths Shoosmiths’s medical negligence team in Northampton, comments:
“This case illustrates precisely why it is important that use of Do Not Attempt Resuscitation orders and their implications are explained clearly to all concerned and that details of their existence are passed on to service providers when people move from one care setting to another.”