Harlow hospital admits policy was not followed

Luciana Antonia Gianfrancesco died at Princess Alexandra Hospital, Harlow following admissions with pneumonia and other health problems.

An inquest into her death was opened in May 2024 but was adjourned after most of the evidence had been heard.

HM Assistant Coroner for Essex Stephen Simblet subsequently issued a Prevention of Future Deaths report after hearing evidence concerning mental capacity assessments and the way a Do Not Attempt Cardiopulmonary Resuscitation, or DNACPR, decision had been documented.

The coroner said there was a risk that future deaths could occur unless action was taken and raised three areas of concern relating to procedures at Princess Alexandra Hospital.

According to the report, a doctor had incompletely filled in a DNACPR form dated April 18, 2024.

It recorded that Luciana Antonia Gianfrancesco lacked capacity to decide whether she should be resuscitated and stated there was "Family agreement", but the coroner said her family did not know the form existed.

The report said the section concerning best interests and mental capacity had not been addressed and the form had not been passed to a more senior doctor for sign-off.

It also recorded obesity, comorbidities and hyperkalaemia, or excess potassium, among her clinical problems.

In its formal response, The Princess Alexandra Hospital accepted that a review had identified "shortcomings in the documentation and recording of the DNACPR decision in this case".

The trust said its policy required DNACPR forms and decisions to be reviewed, endorsed and countersigned by the patient's consultant within 48 hours.

It added: "On this occasion, the Trust did not follow the policy, as the DNACPR form and decision was not endorsed by the Consultant within 48 hours of completion or implementation."

A Cardiac Arrest Review Panel also found the records did not sufficiently demonstrate the clinical reasoning behind the decision, the factors considered, or how the potential benefits and burdens of CPR had been assessed.

The trust said there was also insufficient evidence of a documented reassessment after hyperkalaemia, described as a potentially reversible factor, subsequently improved.

The trust has since introduced a digital ReSPECT system across the organisation to standardise the recording of DNACPR and treatment-escalation decisions.

Staff have also been reminded that conditions including obesity must not be used in isolation to justify a DNACPR decision and that decisions should be formally reviewed when a patient's condition materially changes.

The coroner also raised concerns about how mental capacity was assessed when patients with a history of mental disorder refused or inconsistently accepted potentially life-saving treatment.

The hospital said it had strengthened guidance for staff and reiterated that a mental health diagnosis does not automatically mean somebody lacks capacity.

It said capacity must be assessed for the specific decision involved and at the relevant time.

Further Mental Capacity Act training and clearer guidance on seeking specialist mental health advice are also being developed.

Luciana Antonia Gianfrancesco received her mental healthcare from Essex Partnership University NHS Foundation Trust, which also provides liaison psychiatry at the hospital.

In its response, EPUT said responsibility for carrying out the relevant mental capacity assessments rested with the treating clinical team at Princess Alexandra Hospital.

It asked the coroner to consider removing EPUT as a named recipient of the Prevention of Future Deaths report, while saying it remained committed to working collaboratively with the hospital.

The Prevention of Future Deaths report was issued while the inquest remained adjourned, with the coroner stating that further evidence concerning resuscitation procedures was still to be obtained.