22 June 2015
Patient Dies After Hospital Staff Follow Wrong DNR Order
Hospital medics left a grandfather to die after wrongly following a ‘do not resuscitate’ (DNR) order intended for the bed’s previous occupant.
DNR orders are written by doctors and instruct staff not to resuscitate patients if their breathing fails or their hearts stop beating.
When the pensioner stopped breathing, no attempts were made to revive him as medics believed they were following the family’s instructions.
The appalling error was made because handover documents had not been updated between shifts.
A subsequent internal investigation revealed staff at Wythenshawe Hospital in Manchester, were unclear about their responsibilities during shift changeovers.
The man, in his 70s, was admitted to the hospital’s emergency department with head injuries following a fall he suffered at home in January.
Two days later he was moved to a different ward, before being moved again into a third bed, where the previous occupant had a "do not attempt cardio-pulmonary resuscitation" order in place.
Over the following days, the man’s condition deteriorated and when a nurse noticed he had stopped breathing, she followed the DNR order and notified a doctor to certify his death.
The man’s family are now considering legal action after University Hospital of South Manchester NHS Foundation Trust admitted to a string of errors.
The Trust’s Serious Incident Investigation into the man’s death found that the senior nurse on duty failed to check the patient’s file and wrongly presumed the handover paperwork was correct.
It is crucial that the Trust learns from this hugely tragic incident and radically improves its procedures so that such an appalling error can never be allowed to happen again.
DNR orders must be reviewed regularly, and it is paramount that iron-clad safety protocols exist to prevent any confusion during patient handovers and ensure patient-critical information, such as DNR orders are communicated to the relevant staff.
Stephen Jones is a Senior Clinical Negligence Solicitor at Slater and Gordon Lawyers UK.
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