Man, 80, choked to death after DNR order mix-up

A PENSIONER choked to death on his breakfast because care home staff misunderstood a “do not resuscitate order” on his medical file, a coroner has found.

Robert Murray died at Avalon Nursing Home in Eastbourne in June 2021 after a piece of fruit became lodged in his throat. Staff immediately called 999 when he stopped breathing and a crew of paramedics were dispatched.

But staff then told the dispatcher that Mr Murray had a “do not resuscitate” (DNR) form on his medical records and the ambulance was stood down. He died minutes later, the BBC reported.

At an inquest carried out by Alan Craze, senior coroner for East Sussex, in March last year, it emerged the DNR, in place since 2016, was only meant to apply if Mr Murray had a cardiac arrest.

In a prevention of future deaths report, Mr Craze wrote: “An ambulance, wrongly, was not sent because he had a DNACPR [Do not attempt cardiopulmonary resuscitation] in place.”

“From listening to the 999 call between the registered nurse at the care home and the call operator, and also from evidence heard at the inquest, it is apparent that no one involved understood that there are circumstances when the DNACPR should not be applied.

“I am concerned that this may potentially be an issue elsewhere in the country and further training and clarification is therefore necessary.”

Avalon Nursing Home told the BBC it had updated advice relating to DNACPR forms in all care plans, and staff had attended refresher training.

Mr Murray’s daughter, Wendy, said he may have survived had his file been properly checked. She told the BBC: “As soon as you say DNR, it seems to change what they want to do. If his heart was failing – he was having a heart attack – I could totally understand that.

‘It is apparent that no one involved understood there are circumstances when DNR should not be applied’

But when he died of a choking incident, which is not a natural way of dying, it didn’t get picked up.”

Mr Murray’s daughter described him as a kind and patient father. He had been diagnosed with early on-set Parkinson’s disease at the age of 55.

“He completely agreed with [the DNR],” she said. “It was mainly for his heart, as he had a murmur, but he never wanted to come back [if something happened] from Parkinson’s.”

“He was on quite strong medication, he had shakes, it took him a long time to get himself moving.”