North West Ambulance Service NHS Trust
NHS / Health Body
Action Planned
NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be provided within the next 3 months. (AI summary)
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Dear HM Area Coroner McKenna
INQUEST TOUCHING UPON THE DEATH OF MUHAMMED SAIF ABDUL HALEEM
I write further to the Regulation 28 Report which you issued against the Trust on 27 September 2019, following the conclusion of the Inquest touching upon the death of Muhammed Saif Abdul Haleem.
I understand that a copy of this response will be shared with Muhammed’s family and, on behalf of North West Ambulance Service, I wish to express my sincere condolences for their loss.
Concern Raised
You raised a concern that the information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out of date and was not known to or supported by the clinicians involved in Muhammed’s care at the time of his death. You stated that the evidence was that the number of children living in the community with DNA- CPR’s is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPR’s or Advance Care Plans that are in existence and are current.
Notification of a DNA-CPR
When a clinical decision is made that it would not be in the best interests of the patient to resuscitate and a DNA-CPR is put in place, NWAS receive a notification, primarily from the patient’s GP but also from hospitals, through either ERISS (Electronic Referral information Sharing System) or an Addressbase or NHS.net email account. A DNA-CPR marker would only be placed on the NWAS system against the patient’s address if a notification was received from a healthcare professional or member of staff in a healthcare setting.
A notification of a DNA-CPR via ERISS generally comes from a GP practice who will notify NWAS that a patient has been issued with a DNA-CPR and a marker is applied against the
- 2 - patient’s address. Within the notification the GP will also specify a review date which is entered into the Trust gazetteer system. An automatic email from ERISS would then be sent to whoever created the notification 10 days before the expiration date and the GP practice should inform NWAS that the DNA-CPR marker is to be extended or removed.
A notification of a DNA-CPR via Addressbase or NHS.net generally comes from a hospital or other healthcare setting who will notify NWAS that a patient has been issued with a DNA- CPR and a marker is applied against the patient’s address. A scanned copy of the DNA- CPR may also be provided, which would be archived.
It is important to make the distinction between a DNA-CPR marker and a DNA-CPR. A DNA- CPR marker is an advisory notice of the potential existence of a DNA-CPR for responding clinicians to look to locate a DNA-CPR on scene. A DNA-CPR marker would not, of itself, influence patient care but assists decision making. It does not mean that the Trust definitely will not resuscitate but is simply an indication of the patient’s likely outcome and what is best for their clinical needs. At no point would a DNACPR mentioned on a call be the only source of information for the decision to resuscitate.
Review of a DNA-CPR
The responsibility of review of a DNA-CPR remains with the patient’s referring clinician. If a DNACPR is revoked, in the same way as the agreement is communicated, NWAS would expect the GP practice to communicate the change. If this does not happen, the DNA-CPR marker on the Trust system that remains in place is a warning of the potential existence of a DNA-CPR, which directs the clinician to look for a paper copy of the DNA-CPR when on scene. NWAS policy stipulates the commencement of resuscitation until information can be confirmed. NWAS should also receive requests from GP practices to remove a DNA-CPR marker when a patient has passed away.
Action being taken
It is accepted that the NWAS needs to develop and implement a system which ensures that the NWAS is aware where DNA-CPR markers are out of date and/or require a review. The solution, however, is not a simple one. Consideration has been given to the block deletion of all DNA-CPR markers which are over 12 months old, however this will require careful consideration of the impact this may have on the wider health system and also, appropriate opportunity for the Trust to communicate with GPs and the like about the proposed action.
Your Regulation 28 report has prompted much investigation and discussion both internally and with the Trust commissioners about not only DNA-CPR markers but other markers which are maintained on the Trust’s system.
The Trust’s EOC Governance Group have been tasked with reviewing the position and making recommendations and we will provide you with an update as to progress within the next 3 months.
- 3 - I am sorry that you felt that there was cause to issue a Regulation 28 report and I hope that I have addressed you concerns by this response. If you require any additional information at this stage, please contact the NWAS Legal Services team.
INQUEST TOUCHING UPON THE DEATH OF MUHAMMED SAIF ABDUL HALEEM
I write further to the Regulation 28 Report which you issued against the Trust on 27 September 2019, following the conclusion of the Inquest touching upon the death of Muhammed Saif Abdul Haleem.
I understand that a copy of this response will be shared with Muhammed’s family and, on behalf of North West Ambulance Service, I wish to express my sincere condolences for their loss.
Concern Raised
You raised a concern that the information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out of date and was not known to or supported by the clinicians involved in Muhammed’s care at the time of his death. You stated that the evidence was that the number of children living in the community with DNA- CPR’s is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPR’s or Advance Care Plans that are in existence and are current.
Notification of a DNA-CPR
When a clinical decision is made that it would not be in the best interests of the patient to resuscitate and a DNA-CPR is put in place, NWAS receive a notification, primarily from the patient’s GP but also from hospitals, through either ERISS (Electronic Referral information Sharing System) or an Addressbase or NHS.net email account. A DNA-CPR marker would only be placed on the NWAS system against the patient’s address if a notification was received from a healthcare professional or member of staff in a healthcare setting.
A notification of a DNA-CPR via ERISS generally comes from a GP practice who will notify NWAS that a patient has been issued with a DNA-CPR and a marker is applied against the
- 2 - patient’s address. Within the notification the GP will also specify a review date which is entered into the Trust gazetteer system. An automatic email from ERISS would then be sent to whoever created the notification 10 days before the expiration date and the GP practice should inform NWAS that the DNA-CPR marker is to be extended or removed.
A notification of a DNA-CPR via Addressbase or NHS.net generally comes from a hospital or other healthcare setting who will notify NWAS that a patient has been issued with a DNA- CPR and a marker is applied against the patient’s address. A scanned copy of the DNA- CPR may also be provided, which would be archived.
It is important to make the distinction between a DNA-CPR marker and a DNA-CPR. A DNA- CPR marker is an advisory notice of the potential existence of a DNA-CPR for responding clinicians to look to locate a DNA-CPR on scene. A DNA-CPR marker would not, of itself, influence patient care but assists decision making. It does not mean that the Trust definitely will not resuscitate but is simply an indication of the patient’s likely outcome and what is best for their clinical needs. At no point would a DNACPR mentioned on a call be the only source of information for the decision to resuscitate.
Review of a DNA-CPR
The responsibility of review of a DNA-CPR remains with the patient’s referring clinician. If a DNACPR is revoked, in the same way as the agreement is communicated, NWAS would expect the GP practice to communicate the change. If this does not happen, the DNA-CPR marker on the Trust system that remains in place is a warning of the potential existence of a DNA-CPR, which directs the clinician to look for a paper copy of the DNA-CPR when on scene. NWAS policy stipulates the commencement of resuscitation until information can be confirmed. NWAS should also receive requests from GP practices to remove a DNA-CPR marker when a patient has passed away.
Action being taken
It is accepted that the NWAS needs to develop and implement a system which ensures that the NWAS is aware where DNA-CPR markers are out of date and/or require a review. The solution, however, is not a simple one. Consideration has been given to the block deletion of all DNA-CPR markers which are over 12 months old, however this will require careful consideration of the impact this may have on the wider health system and also, appropriate opportunity for the Trust to communicate with GPs and the like about the proposed action.
Your Regulation 28 report has prompted much investigation and discussion both internally and with the Trust commissioners about not only DNA-CPR markers but other markers which are maintained on the Trust’s system.
The Trust’s EOC Governance Group have been tasked with reviewing the position and making recommendations and we will provide you with an update as to progress within the next 3 months.
- 3 - I am sorry that you felt that there was cause to issue a Regulation 28 report and I hope that I have addressed you concerns by this response. If you require any additional information at this stage, please contact the NWAS Legal Services team.