Peter Clarke was not treated by doctors after going into cardiac arrest as a nurse had spotted the form in his files and, even though it was blank and had not been filled in, told other ward staff he should not be revived.
The blunder emerged at an inquest into the incident at Derby Hospitals NHS Trust, where bosses revealed staff had been ‘routinely’ placing the forms alongside medical records before they had been correctly signed and witnessed by senior doctors.
The errors go against the usual Trust policy on using the forms and mean the documents were inserted into files without the consent of patients.
It has affected an unknown number of patients and it is not known how long the practice was going on.
The good news is that 'lessons have been learned and procedures changed' :
Dr Robert Hunter, Derby and South Derbyshire Coroner, recorded a verdict of natural causes. He said that on the balance of probabilities the failure to carry out resuscitation did not cause or affect Mr Clarke’s death.
But he added: "The circumstances have highlighted faults within the system. If anything has come out of this, it's improved the policy for future patients."
Miss Fowlie said that several changes in procedure had been made to prevent a repeat occurrence.
Blank Do Not Resuscitate forms were no longer being routinely filed into patients’ medical records by clerical staff, and greater checks and balances had been implemented when it came to deciding whether to resuscitate a patient.
Just wait until they start adding the Terry Pratchett 'I really want you to top me if I can't do it myself (and save a lot of NHS budget)' forms.