Wayne Rouse was mistakenly thought to have signed a DNR order at Tandara Lodge aged care

An elderly man died on the floor of his room at a northern aged care centre after staff mistakenly believed he had signed a “do not resuscitate” order – only realising too late this was not the case.

Tandara Lodge aged care centre, in Sheffield.

An elderly man died on the floor of his room at a Sheffield aged care centre, after staff mistakenly believed he’d signed a “do not resuscitate” order – only realising too late this was not the case.

While medical evidence suggested he may not have survived due to his extensive medical history and comorbidities, Wayne Victor Rouse died on June 14 this year from sudden cardiac death – after CPR was not performed on him.

At the time of his death, Mr Rouse, 68, was a resident at Tandara Lodge at Sheffield and suffered from a range of health problems including congestive cardiac failure, hypertension, and chronic obstructive pulmonary disease.

In his record of investigation into Mr Rouse’s death, Coroner Robert Webster noted the failure to provide CPR was due to “inadequacies in [Tandara Lodge’s] documentation, and in the communication to staff of a resident’s wishes”.

On the morning of Mr Rouse’s death, he used the call bell in his room to sound for assistance, but the only two staff rostered on at the time were busy with another patient and did not respond to him for eight minutes.

Mr Rouse was then found unconscious on the bathroom floor, with no pulse and staff did not begin CPR despite calling for a registered nurse and calling an ambulance, because they thought he had an active DNR order.

It was noted in the report that an ambulance was called while Mr Rouse was still breathing, and that only once he had been pronounced dead that staff discovered that one of his goals of care had been resuscitation.

His medical goals had not been “immediately available” to clarify the orders, Mr Webster noted, and because of the “clear error demonstrated by staff”, he arranged for a coronial nursing consultant to consider its records.

“Once ambulance personnel arrived it was discovered then the goals of care were for resuscitation,” the nursing consultant noted in the report.

“By this time, 15 minutes had passed with no cardiac output. The likelihood of survival in those circumstances is extremely low.”

On the night of Mr Rouse’s death, there was only one registered nurse and one care worker rostered on to work, with Mr Webster noting the staffing levels were a “risk” Tandara Lodge needed to address.

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A series of changes have since been made by Tandara Lodge in the wake of Mr Rouse’s death, including: having residents sign an updated and approved goals of care form, colour-coded signs in rooms indicating their resuscitation status, a standardised document storage in the common staff area, a quick reference system to identify residents for resuscitation.

Staff education and training has since been conducted for all staff on the changes made, and the not for resuscitation section on the staff handover sheet has been removed to eliminate it as a potential source of error.

“There is a clear organisational failure at the [Tandara Lodge] in the communication of the residents’ goals of care,” the consultant said, before adding that they believed staff had been working in “good faith” at the time – comments which Mr Webster accepted.

Mr Webster said while Mr Rouse died in “very unfortunate circumstances”, the inadequacies in his care would be mitigated by the changes implemented by the facility.

“Had CPR been provided to Mr Rouse in accordance with his expressed wishes the medical evidence appears to suggest he would not have been revived,” he noted.

He recommended that Tandara Lodge review its staffing levels, and ensure it has adequate staff rostered on so more than one resident could be helped at once.