Is inadequate training the real cause of DNACPR death?
copied from the Facebook page, and originally posted by Alexandra Hayward-Barrell
Is inadequate training the real cause of DNACPR death?
The Nursing Standard published an article on the 5th August about the unnecessary death of a nursing home resident in East London, after the four registered nurses on duty failed to understand what the term DNACPR actually means. The headline of this article was:
DNACPR confusion contributed to care home death
This tragic case underlines the importance of good, clear and regular training, that includes an assessment of knowledge and understanding as well as the practical elements of the many skills nurses today are required to have.
The details of this case as identified by the coroner, are that this lady, aged 79, with dementia, died from acute respiratory failure after choking on food, and the four Registered nurses on duty failing to recognise that the DNACPR in place for her did not apply, as the cardiac arrest that she suffered as a result of poor and 'ineffective' first aid for her choking, was a reversible cause. In his Regulation 28 report to prevent future deaths, senior coroner, Mr Irvine, raised concerns about the responses of the staff, describing it as 'delayed and disorganised', going on to state that 'Despite four registered nurses being present at the scene no effective leadership of the emergency response was witnessed'. This is worsened by the nurses not commencing CPR until 10 minutes after the lady suffered a cardiac arrest, despite having been instructed to do so, three times by the London Ambulance Service call dispatch handler.
Anyone employed in any occupation in the UK today, will be aware of the need for regular first aid training, as regulated by the HSE. A loophole in this, is that those individuals who are Registered as Healthcare Professionals are exempt from attending this training, as they are deemed to be appropriately skilled in the basics of Emergency first aid. As a registered nurse of over 30 years, I have attended more Basic Life Support and First Aid courses than I care to recall, and am very aware of the differences in how these courses are delivered and assessed. One thing that I am very sure of, is that I had never been required to complete an assessment of knowledge and understanding after attending a Basic Life Support course, and often not even to successfully complete a cycle of CPR or choking first aid, both of which are basic but essential skills. Working as a clinical skills educator in health and social care, I have been horrified by the lack of physical skills demonstrated by attendees in Basic Life Saving, and the confusion around what a DNACPR actually stands for.
According to the UK Resuscitation Council, the term DNACPR means that if an individual has a cardiac arrest or dies suddenly, they will not be given CPR, and refers to CPR (chest compressions) only. The decision to have a DNACPR may be something that they have decided themselves, or where they lack capacity, may be in place after a Best interests decision has been made, considering expectations of the likely outcome if CPR were attempted. A DNACPR is also not legally binding, and can be suspended or revoked at anytime. A DNACPR does not mean 'DO NOT TREAT', so other life-threatening conditions, such as anaphylaxis, choking, infection, etc. should all be treated as usual, and it is this that causes the greatest confusion around DNACPR statements, and something that should be included in all Basic Life Support training sessions.
Today as a clinical skills educator working in health and social care I am in a position where I can start to make a difference to this. All of our courses, no matter what the subject or skill, includes an assessment of knowledge and understanding, where skills are required we assess these and we do fail those who do not reach the minimum required standards.
There is a lot to discuss in there, and at the moment I don't have the time to do it. But, as a start I will make one comment. We are told that the lady was 79. We are also told that 'the arrest was 'reversible' - at least, we are told that the arrest was because of 'a reversible cause'. We don't know how 'frail' this lady of 79 years was - and chest compressions of a healthy 20 year old whose heart has stopped because of chocking, are a different matter from chest compressions on a 79 yrs-old who might have what I'll call 'a fragile rib cage' whatever the reason for the arrest.
Of course, if the choking was observed, then an attempt to address that should have been made at the time, which if successful would have prevented an arrest.
I will point out, that if a nurse on-scene is aware of a 'valid and applicable' 'DNACPR', then the nurse would be acting correctly in telling the London Ambulance Service call dispatch handler 'you cannot 'instruct' me to attempt CPR'. If the person who calls 999 believes that CPR is appropriate then asking the call handler how to perform CPR is 100% appropriate - but if you call 999 and they tell you to attempt CPR, when you know you should not attempt CPR, then you should not attempt CPR.
See my thread at
for some discussion of 'not attempting CPR even if a 999 call handler tells you to do that'.
It is also very challenging, to decide whether or not it was in this lady's MCA Best Interests to start CPR 10 minutes after she had arrested - I don't think that I would want CPR to be attempted (started) on me, if my heart had been stopped for 10 minutes.
Cpr should start immediately heart stop
It’s depends on the various factors
Firstly if this is anticipated and discussed with the Doctor, family, palliative team and if they have representatives. And end of life plan is in place UCP- At this situation you do not give CPR
Second if above things are in place but the resident is having any accidents like choke, fall, infection in this situation you must act as fast as possible and follow the procedure like a normal individual without DNACPR