Report Date


Case Against

Cardiff and Vale University Health Board



Case Reference Number



Early resolution

13. Mrs X complained about the Health Board’s refusal to remove a ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) form from her medical records. She explained that she felt worried, particularly if it became necessary for her to be readmitted into hospital.

The Ombudsman found that the decision about the appropriateness of CPR would usually be reviewed upon a further hospital admission. She had been informed that the DNACPR did not mean she would not receive all active treatment for a presenting condition, and if she was readmitted, she could make her wishes clear to the admitting team that she wished to be resuscitated. Regarding the removal of the DNACPR from the medical records, the Health Board were correct in saying that the medical records were legal documents which could not be altered in any way. The Ombudsman found no failings in the way in which the Health Board dealt with Mrs X’s request to remove the DNACPR form from her medical records.

However, in acknowledging her concern about admission to hospital, the Ombudsman considered whether there was anything further that could be done to alert staff to review the DNACPR. The Health Board agreed to:

• put a note on the Clinical Portal, the electronic records and Mrs X’s paper records within 30 working days from the date that the Ombudsman issued his decision