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Miscommunication in Hospitals Leads to DNR Errors

There have been two cases in the news recently involving ‘Do not resuscitate’ (DNR) orders being mistakenly applied. 

Such incidents underline the fact that effective communication between doctors and nurses as well as between medical professionals and the families of patients is vital to prevent errors from occurring. It is very disturbing to note that the mistakes made in both of these cases could have been prevented.

A DNR order, also known as a Do not attempt to resuscitate (DNAR) order on a patient’s file means that a doctor is not required to resuscitate that patient should their heart stop beating.

A DNR order is designed to prevent prolonged and unnecessary suffering. The usual circumstances in which it is appropriate not to resuscitate are when there is no benefit to the patient and when the benefits are outweighed by the burdens.

Patients who have the mental capacity to understand their options can make decisions to refuse a particular treatment themselves. However, not all patients will have capacity.

When a person does not have capacity to participate in the decision-making process, it is the responsibility of the senior responsible clinician to make any decisions regarding resuscitation. Such a decision should always be made in the patient’s best interests and whenever possible, this should take into account the views of the patient’s family or others close to them.

My colleague Zak Golombeck has previously commented on a case in which the Court of Appeal decided that the failure to consult an individual as to whether a DNAR be placed in their notes was a violation of their human rights. A similar case is now being brought by Elaine Winspear after she discovered that a DNAR was placed on the file of her son Carl, who had cerebral palsy, shortly before he died.

Mrs Winspear was understandably extremely distressed to discover that such a fundamental decision was made without first consulting her and she is now seeking a declaration that the DNAR breached Carl’s human right to respect for private and family life. The case was recently heard in London’s High Court and judgment is awaited.

Another case that has recently made the headlines involves the sad death of Jack Adcock, a six year-old boy who died of a cardiac arrest in February 2011 as a result of negligent medical treatment. Our clinical negligence team has previously commented on events surrounding Jack’s tragic death and we have been following the progress of the subsequent criminal investigation.

The care Jack received was so shockingly inadequate that a doctor and nurse treating him at the time have been found guilty of gross negligent manslaughter. Another nurse was cleared of the same charge. Jack, who had Down’s syndrome and a heart condition, was admitted to Leicester Royal Infirmary with vomiting and diarrhoea but died 11 hours later from a cardiac arrest caused by sepsis triggered by pneumonia.

One thing that I am sure added to the distress of Jack’s family was the fact that the doctor involved with Jack’s care, at one point mistook Jack for another patient who had a DNAR in place and thereafter momentarily stopped life-saving treatment.

The error was picked up by a junior doctor and resuscitation was resumed. It was accepted by the prosecution during the subsequent trial that Jack was already past the point of no return when this error occurred. Nonetheless such an error is clearly unacceptable and in different circumstances, such an error could have been critical to the patient’s survival.

Both cases demonstrate mistakes that could have been avoided with better communication by medical professionals. This is something our clinical negligence solicitors see a great deal of at Slater and Gordon and it is always extremely sad to see cases where injuries could so easily have been avoided had the medical professionals involved communicated with each other more effectively.

Claire White is a senior clinical negligence solicitor at Slater and Gordon in Manchester.

If you or a member of your family suffered from negligent treatment in hospital, call our Medical Negligence Solicitors for a free consultation on freephone 0800 916 9049 or contact us online.

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