A controversial outsourcing company is refusing to act after one of its ambulance crews was mistakenly told that a disabled campaigner had agreed to have a “do not attempt resuscitation” (DNAR) order placed on her records.
Anna Morell was about to use a non-emergency G4S ambulance to take her to a routine appointment when one of the paramedics asked for written proof that she did not want them to attempt to resuscitate her if her heart or breathing stopped on the journey.
She was horrified when the paramedic showed her his mobile phone screen, which showed he had been given the instruction: “Pick up DNR.”
Although he immediately called a G4S colleague and ensured the note was taken off her records, Morell said the incident was “deeply disturbing” as she is always extremely clear with G4S that she does not have a DNAR in place.
Morell (pictured), media and communications manager for Disability Rights UK, was later told there had been an administrative error, but she said the mistake was “inexcusable”.
There have been repeated, serious concerns raised about the wrongful placing of DNAR notes on disabled people’s medical records throughout the pandemic.
In March, the Care Quality Commission (CQC) found more than 500 DNAR decisions put in place since 17 March 2020 “had not been agreed in discussion with the person, their relative or carer”.
The true figure will have been even higher because the number was based on responses from only about 2,000 of the 25,000 adult social care providers CQC approached for information.
G4S said this week that its crews always ask for confirmation that a DNAR is in place before starting a journey, and that a verbal apology was made to Morell when the crew member realised the error had been made.
Morell said she had been “incredulous” when she realised the crew had been told that she had a DNAR in place.
She said: “The crew took swift action to have it removed, and reassured me that the protocol is to visually see the document, without which they have to resuscitate regardless of whether a patient verbally insists they have [a DNAR].”
But she said that people are “fallible”.
She said: “If the process goes wrong at the admin end of the process, it can also go wrong at the sharp end of the process.
“Disabled people, myself included, are extremely nervous about the ability of third parties to place erroneous information about DNAR notices on our records.
“This has happened in care homes at the start of COVID, it has happened at care homes outside of COVID, and I know other disabled people who have also found out from patient transport crews in other parts of the country that they have had DNAR notices placed on their records in error.
“A simple slip of a key without due care and attention can be the first step in a domino effect which leads to loss of life.”
She said G4S needed to implement a “failsafe process from start to finish” to ensure that such an error “unequivocally cannot happen”.
She has suggested to G4S that it uses clearer wording when its call centre staff question service-users about whether a DNAR is in place, one that requires a yes or no response, and that a copy of the booking details is sent to those passengers who can use email as a “failsafe”.
Kamran Mallick, chief executive of Disability Rights UK, said: “Disabled people’s confidence and trust in systems were shaken last year when we heard about DNRs being applied to them without consent during the pandemic.
“I have also been consistently asked if I have a DNR in place when booking hospital transport.
“It is chilling to be asked this again and again and Anna’s experience demonstrates that an administrative error could lead to a devastating outcome.
“Bland reassurances that the ‘error has been corrected’ are far from reassuring.
“How many similar errors have not been identified?
“The NHS and its contractors must stop working from the assumption that disabled people’s lives are of less value.”
Morell regularly uses the G4S non-emergency patient transport service (NEPTS), which is provided through a contract with NHS Kent and Medway Clinical Commissioning Group.
This week, G4S refused to say how the mistake was allowed to happen; how seriously it took Morell’s complaint; and what action it would take to ensure that it never happened again.
Instead, a G4S spokesperson said in a statement: “The safety of those using our service is of paramount importance, which is why we have processes in place to identify any recording errors at the first opportunity.
“Our crew will always ask the patient for confirmation of a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) form before a trip, and without this confirmation, the crew would start resuscitation in the event of cardiac arrest.”
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