Dr Richard Dune

09-08-2023

DNACPR mistakes in care: Governance, training and compliance

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How poor DNACPR and resuscitation decisions highlight the urgent need for robust governance, digital compliance systems, and statutory training in care settings.

"Action should be taken." - Coroner Darren Stewart OBE

The recent BBC report into the tragic death of 74-year-old Kathleen Gregory at Beccles Care Home has sent shockwaves through the health and social care sector. Mrs Gregory, who choked on her lunch, was not resuscitated by the attending paramedic, who wrongly assumed she was not for resuscitation after misinterpreting her ReSPECT form.

The coroner has since issued a Prevention of Future Deaths Report, raising urgent questions about:

• How frontline staff interpret emergency care plans
• Whether policies and procedures are clear and accessible
• If statutory and mandatory training adequately prepares staff to act under pressure
• How organisations use digital compliance systems to ensure the right decision is made at the right time.

Sadly, Mrs Gregory’s case is not an isolated incident. It exposes the dangerous gap between policy and practice, a gap only robust governance, compliance frameworks, workforce development, and digital tools can close.

A sector-wide pattern of governance failures

During the COVID-19 pandemic, reports emerged of blanket Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions being applied in some care settings without proper consultation with patients or families. This prompted:

• Investigations by the Care Quality Commission (CQC)
• Regulatory warnings
• Scrutiny from the UK COVID-19 Inquiry.

The Inquiry heard repeated testimony about:

• DNACPR decisions are being made without a mental capacity assessment
• Frontline staff assuming care home residents were automatically not for resuscitation
• A lack of understanding of what DNACPR and ReSPECT forms mean in practice These aren’t just training gaps; they’re breaches of law, ethics, and regulatory compliance frameworks.

The human cost of compliance failures

• CQC (2021) - Inappropriate DNACPR decisions found in 1 in 10 care home inspections
• Only 44% of providers had comprehensive staff training in emergency care decisions
• BMJ Quality & Safety - Nearly 60% of DNACPR decisions were not properly discussed with the individual or their family.

This is not just a training failure, it is a governance and compliance system failure that undermines public trust and patient safety.

The Beccles case: What went wrong?

According to the coroner’s findings:

• The paramedic misinterpreted the ReSPECT form, assuming it prohibited resuscitation in a choking incident
• In fact, the form did not preclude intervention for reversible events like choking
• The death was deemed accidental but potentially preventable
• The coroner warned there is “a risk of future deaths” without immediate action.

This raises critical compliance questions:

• Was statutory and mandatory training fit for purpose?
• Were policies and procedures up to date and easy to access in an emergency?
• Did staff have real-time access to the care plan through a secure document repository?
• Were escalation procedures embedded into the organisation’s governance framework?

Legal and regulatory compliance obligations

The law is unambiguous

• Mental Capacity Act 2005 - DNACPR decisions must follow a capacity assessment and, if capacity is lacking, be made in the individual’s best interests, involving their family or legal proxy.
• Human Rights Act 1998 - Article 2 (right to life) and Article 8 (right to private and family life) apply directly to life-sustaining decisions.
• Equality Act 2010 - Resuscitation decisions cannot be based on age, disability, or diagnosis alone.

CQC regulations that apply

• Regulation 11 - Consent: Individuals must be included in decisions about their treatment.
• Regulation 12 - Safe Care and Treatment: Care must follow current guidance and clinical best practice.
• Regulation 17 - Good Governance: Providers must have systems to monitor, audit, and train staff on emergency protocols.

Compliance here is not optional; it is a legal requirement.

The Training room reality: Dangerous misconceptions

At The Mandatory Training Group, we’ve delivered thousands of CPD-accredited online training courses to care providers across the UK. We still regularly encounter frontline staff, even experienced clinicians, who believe:

• “If there’s a DNACPR, we can’t help the person at all.”
• “ReSPECT means no intervention.”
• “All care home residents are automatically DNACPR.”

These misconceptions can cost lives. Even after completing certified resuscitation training, many staff lack:

• Confidence in the Mental Capacity Act application
• Clarity on when and how to begin CPR
• Skills to interpret ReSPECT/DNACPR documentation in high-pressure situations
• Understanding of escalation pathways under their governance and compliance framework

Governance and digital infrastructure: Closing the gap

Good governance is not just policies; it’s ensuring they work in practice. This requires:

• Up-to-date, evidence-based policies and procedures
• Role-specific statutory and mandatory training
• Real-time access to care plans through secure document repository and archiving systems
• Clear escalation procedures supported by a Training Management System (TMS) and Learning Management System (LMS) for tracking workforce competency

Without these governance structures, frontline staff are left to make life-or-death decisions without the tools or confidence to act correctly.

Digital compliance systems: The ComplyPlus™ approach

Through our ComplyPlus™ regulatory compliance management software, we help providers integrate governance, compliance, and workforce development by:

• Providing a secure document repository for care plans, DNACPR/ReSPECT forms, and policies, accessible to authorised staff in real time
• Offering an integrated LMS for delivering statutory and mandatory training and tracking CPD
• Managing version control of policies and procedures to ensure CQC inspection readiness
• Delivering audit trails and compliance dashboards for proactive governance reviews.

Because in emergencies, seconds matter, and digital compliance systems can make those seconds count.

Key actions for providers

To prevent future tragedies, providers must:

• Review and update all DNACPR and ReSPECT policies and procedures in line with current law and regulatory frameworks.
• Deliver scenario-based statutory and mandatory training covering:

• Mental Capacity Act compliance
• Consent and best interests
• Interpreting ReSPECT/DNACPR under pressure

3. Audit compliance systems for:

• Policy access and version control
• Real-time care plan availability
• Staff competency records via LMS/TMS

4. Invest in regulatory compliance software to integrate:

• Training
• Governance frameworks
• Digital document storage and archiving

5. Engage staff in supervision and reflective practice to embed learning into daily operations.

Final thoughts: Life-saving decisions are a governance responsibility

Resuscitation decisions are not just clinical judgments; they are compliance obligations, ethical responsibilities, and governance matters.

Whether you are an NHS Trust, a large care group, or a single care home, your organisation must ensure that:

• Your policies and procedures are watertight
• Your statutory and mandatory training is relevant and up to date
• Your digital compliance systems enable real-time access to life-saving information
• Your workforce is trained, confident, and supported by robust governance frameworks

Because when assumptions kill, only governance, compliance, and training can save lives.

Protect your organisation with ComplyPlus™

At The Mandatory Training Group, I have led the development of ComplyPlus™, our regulatory compliance management software designed to:

• Centralise your policies and procedures in a secure document repository
• Deliver and track statutory and mandatory training via our integrated LMS
• Manage workforce compliance through a robust TMS
• Provide real-time compliance dashboards for governance oversight

Learn more about how ComplyPlus™ can protect lives and strengthen your compliance framework here: Click to learn more

By aligning training, governance, and digital compliance systems, you can move from reactive responses to proactive life-saving readiness.

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