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Blanket DNACPR orders imposed ‘at local level’ during pandemic, CQC finds

19 March 2021

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Some local areas proposed blanket Do Not Attempt CPR orders for people with a learning disability during the pandemic, an investigation by the CQC has found.

The CQC report cited examples of a CCG that placed a blanket ban on Covid-19 positive people with learning disabilities being sent for hospital treatment, while a GP was found to have sent out letters to care homes about putting blanket DNACPR decisions in place.

The regulator said it also found evidence of policies being ‘quickly challenged and retracted’.

‘We were told that there were some blanket DNACPR decisions imposed by quickly revoked, and some were considered but not initiated after discussions with the CCG,’ the report said.

The Government commissioned the CQC to carry out a review of DNACPR decisions last October, in response to concerns they were being applied inappropriately during Covid.

An interim report in December concluded there had been ‘unacceptable and inappropriate’ use of the orders at the start of the pandemic.

In its latest report (17 March), CQC included evidence collected from a national public survey, an information request to adult social care providers, and fieldwork with seven CCGs.

While it found that most health and care providers were ‘not aware’ of inappropriate DNACPR decisions, the information request revealed that 6% of 2,048 adult care services felt people in their care had been subject to blanket DNACPR decisions ‘at any time since 17 March 2020’.

The figures also appeared to show an increase in the number of DNACPR decisions, CQC said, with respondents stating that 36% of people in their care had a DNACPR decision in place between 17 March and December 2020 compared with 28% at 16 March 2020.

The increase was larger in nursing homes, with the percentage of people with a DNACPR decisions increasing to 74% on 16 March to 92% from 17 March onwards, CQC found.

Human rights breaches

The regulator also found ‘a worrying picture’ of poor involvement of people using services, poor record keeping, and a lack of oversight and scrutiny of the decisions being made.

This included that some DNACPR decisions put in place since 17 March 2020 had not been agreed in discussion with the person or considered as part of a personalised care plan.

It added that while many of these decisions made during the pandemic had been ‘reviewed in response to national messaging and support’, some were still in place in December.

CQC said the figures raised ‘serious concerns’ that individuals’ human rights – to be involved in DNACPR decisions about themselves or their families – were potentially being breached in more than 500 cases across the adult care services it surveyed.    

It added: ‘As the majority of people receiving care in adult social care locations are disabled people, including older disabled people, these figures raise concerns about whether the providers making these decisions were at risk of breaching the Equality Act 2010.’

The investigation also found that the pressure of responding to Covid-19 had impacted on the time staff had to hold meaningful conversations with patients and their relatives, and that the large amount of rapidly changing guidance during the pandemic had also presented barriers.

However, the CQC added that the issues raised in the report ‘pre-date the pandemic’.

Among its recommendations, the CQC called for a new Ministerial Oversight Group to be set up to look in depth at the issues identified and oversee the required changes.

It also recommended that health and social care staff are given ‘clear and consistent’ training in line with a national, unified approach to DNACPR decision making.  

Rosie Benneyworth, CQC’s chief inspector for primary care, said personalised advance care planning, including DNACPR decisions, was ‘a vital part’ of good quality care.

‘Covid-19 has brought this to the fore but these are not new issues. While this rapid review was not asked to make judgements on how decisions might have impacted individual cases, we have to take this opportunity to address these problems,’ she said.

‘We need to make sure that people have the opportunity to discuss their wishes about care and treatment in a compassionate and person-centred way.’

This story first appeared on our sister title, Healthcare Leader.