A blunder at a Derbyshire hospital led to the death of a cardiac patient, after staff mistakenly thought he had requested not to be resuscitated.

The Daily Mail reports that in January 2009, 86-year-old widower Peter Clarke from Belper in Derbyshire suffered a heart attack while on a hospital ward at Derbyshire Hospitals NHS Trust. He had been admitted with flu-like symptoms from the Ada Belfield Care Home in Belper, where he had lived for the previous eight months.

Clerical staff had inserted a ‘Do Not Attempt Resuscitation’ form into his notes – and although the form had not been filled in as required, ward staff advised colleagues not to resuscitate the father of two when he suffered a cardiac arrest.  He subsequently died.

An inquest heard from health chiefs at the trust that staff had ‘routinely’ been placing Do Not Attempt Resuscitation orders (DNARs) with patient medical records before they had been correctly signed and witnessed by senior doctors. The practice was heard to be in direct contravention of the trust’s usual policy, as it meant the forms were inserted in patient files without the consent of the patient.

Mr Clarke suffered from heart disease, but after suffering a heart attack on the ward, nurses said they did not call a doctor because of the DNAR in his notes and a nursing shift handover note from a colleague, which suggested the decision not to resuscitate him had been made for clinical reasons.

An hour later, however, a nurse discovered there was no information in Mr Clarke’s medical records to support this assumption. A DNAR form requires the signatures of the patient’s family, plus a consultant and a senior doctor who has been qualified for at least two years.

Medical staff at the trust have said it was ‘unlikely’ that Mr Clarke would have survived the heart attack, even with intervention.

However, the revelation at his inquest that DNARs were being routinely inserted into patient files without the knowledge or consent of the patient or their family – and against the trust’s official policy – has led to the forms being removed from the files.

A hospital spokesman said that the trust believed no other patients had been put at risk by the practice. Mr Clarke’s family has received an apology from the trust.

Coroner Dr Robert Hunter recorded a verdict of natural death and said:

‘The circumstances have highlighted faults. If anything has come out of this, it’s improved the policy for other patients.’

The trust has also issued a statement regarding Mr Clarke’s death:

‘The patient had severe coronary artery disease failure and other complications – and it is unlikely the resuscitation would have made any difference.’

Mr Clarke had served in the RAF and had worked at the Rolls-Royce factory in Derby. His daughter Linda Woodiwiss, 61, said:

‘He was visited by family every day and there was no discussion between the hospital and us about whether or not to revive him.

‘Had we been asked, then we would definitely have told them to revive him and do whatever they could. That is what you expect of a hospital.’

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