do not resuscitate

Bunny Pinnington was the Nurse at a Swansea (South Wales, UK) Special School for children with profound disabilities for six years. In 1996, she was given by her (non-medically-qualified) Head Teacher a Do-Not-Resuscitate order on child A and another child. This was done against the opinion of A’s consultant and without any consultation with the carers. Since then, she has been effectively driven from her job following her refusal to accept the Head Teacher’s instruction.

Although, she initially had the support of the local Royal College of Nursing (RCN) Officer, David Wallace, her subsequent representation by him and by solicitors appointed by the RCN was the subject of complaint concerning their lack of specialist understanding, in particular on educational law. Now, having given her advice that misled her to believe she had already exhausted possible internal procedures and therefore her employment was effectively terminated, we understand the RCN is no longer supporting Bunny’s case, despite a Court judgement in her favour. Bunny, meanwhile struggles on to pursue this important case of principle at her own expense, but with the continued support of A's carers, her grandparents. They have said,

“Bunny has lost everything through standing up for her principles. She is fantastic. A is a very happy child. She cannot move but she smiles and is very rarely ill. If she collapsed, we would expect the nurse to give her mouth to mouth [resuscitation].”

The RCN made a joint statement with the British Medical Association (BMA) and the The Resuscitation Council (UK) in June 1999; it seems that Mrs. Pinnington’s case represents two clear breaches of this statement in that “responsibility for a DNR decision rests with the consultant or general practitioner in charge of the patient’s care” (para. 3) and that “Relatives and others close to the patient should be assured that their views on what the patient would have wanted will be taken into account in decision making.” (para. 9) The RCN said it had given Mrs. Pinnington “considerable financial and other support”. That would only be sufficient were the RCN to pursue this critical issue of medical principle and ethics to its end. We believe that there is a critical issue, especially for those medically qualified staff who work outside wholly medical settings and may have non-medical managers impinging on medical decision-making and diagnosis.

We would like the RCN to clarify why it has ceased to support Bunny Pinnington and the pursuit of the critical principles of clinical authority and the right for close family consultation, especially given the disabilities of the child involved. FTC awaits a response to a letter it has sent to the RCN about this matter. [More to follow] [Nov 2000]

Update April 2001 Nurse & FtC member Bunny Pinnington is raising criticisms of the way the UKCC fails to adequately deal with complaints against professionals.

She has written to the NHS Executive that "the UKCC has failed again and again to meet its own objectives. We understand that they exist to establish and improve standards of training and professional conduct for Nurses, Midwives and Health Visitors. They fail to accomplish anything like that and their actions are certainly not in the public interest.. .We can show that the UKCC has not taken complaints made to them seriously, and that it has failed to support very serious complaints. There is no transparency with regard to their informing complainants of the reason why they refuse to take action." She says standards of nurses are not being monitored and complaints are not recorded. She quotes the August 1998 Report on a Review of the Nurses, Midwives and Health Visitors Act 1997: "There have been too many high profile cases that, reported by the media, have led to a perception that the UKCC is not providing the protection it should.. .There is a serious mismatch between what Council is seen to be doing and what others think it should be doing."

Bunny is being supported by the families of others who have been failed; she includes letters from parents who complained about a nurse "who took it upon herself not to resuscitate our physically handicapped son... it is possible that as a result of her non action that our son died. The nurse made this decision without our knowledge and consent and without any involvement from a doctor.. .yet the UKCC took no action and would give us no explanation."

Another case: "...triage nurse who ignored a GP letter and gave a low triage level. Their son, Neil, died alter collapsing in the A & E department after waiting nearly 4 hours. The UKCC took no action."

A daughter, writing of her father's death in a hospital: "I got in touch with the UKCC and provided them with names, dates etc. of all the incidents that involved nurses. These incidences were neglect, physical abuse, verbal abuse and many more. The UKCC, in their wisdom, decided not to take the case any further and no member of the nursing staff were reprimanded."

These are in addition to the case which led to Bunny losing her own job in opposing a instruction not to resuscitate a disabled child; the carers of the child complained to the UKCC in 1998 when Bunny 's replacement Nurse accepted the instruction. After 21 months, the UKCC refused to take the matter further.

As one of the parents involved wrote: "What on earth is the point of the UKCC - I suppose it is just there to protect the staff and keep them in a job."

Chris Clode, Network Coordinator

1. Terms of Reference of Study.

While we recognise that the Study is not an alternative stage to re-run employment matters specific to Mrs. Bunny Pinnington, we have considerable concern at the narrow remit of the Study and its Terms of Reference. We have argued that issues at the centre of the Pinnington Case were parallel to those at the core of the Waterhouse Inquiry, namely:

a) the flouting by senior managers of agreed procedures put in place to protect vulnerable children;

b) the harassment and denial of due process to those seeking to raise concerns on behalf of those children.

Although the child concerned was not accommodated or looked after by the Local Authority (as with the Waterhouse cases), the central issue in this matter was the denial of life to a child; even most of the Waterhouse victims were not threatened to the extent of the child in this case, yet the qualified professional challenging the instruction not to resuscitate from an unqualified person, was marginalised and finally disposed of in a way similar to Alison Taylor and other Waterhouse witnesses in North Wales. Like the Waterhouse evidence, the Pinnington Case demonstrates another case in Wales of the mutual protection of well-networked senior staff at the cost of another failure to protect a child. The Assembly are well aware, also, that the Pinnington Case is not simply historical and could be repeated today, because Freedom to Care and CloverCare consultancies have provided the Assembly with large quantities of evidence on similar matters that are recent or current within Welsh Local Authorities.

We would hope that the Study would address some of these wider issues of how safe care can be insured within a wider corporate environment where the protection of children (and other vulnerable people dependent on Council services) is not seen as a priority and indeed appears to be poorly understood, at best.

2. DNR Policy.

Firstly, having seen the extensive documentation on the Pinnington Case, including correspondence within Education and correspondence to and from Mrs. Pinnington, the Davieses (the child's carers), the Assembly and the RCN, Freedom to Care believes that there is clear evidence that a DNR instruction was in place in relation to the child, A; that its source was the Head Teacher, who altered A's Care Plan; that this was done without the consent of the medical consultant or GP and without consultation with the grandparents, the carers. She gave instructions to not resuscitate two children making her position clear in her letter dated 14^th. May 1997. To further compound the issue the Head Teacher along with a senior member of the Authority sought a DNR order for child A without parental knowledge or consent. The Authority undertook a wholly inadequate investigation without element of independence and effectively took no action regarding this matter. Some months later the Head Teacher again took the initiative to get involved in medical matters by changing a child’s care plan without parental or medical knowledge, that change to the care plan would have proved fatal if followed. Again the Authority investigated itself, did not connect the two issues and did nothing.

DNR orders clearly have no place in this school or any other school. If a child is well enough to be sent to school in the morning then it is reasonable to expect that the child will be sent home after school. Also it is reasonable to expect that if anything happens to that child while in school then all efforts will be made to ensure his/her health and safety. All medical decisions must be made by medically qualified staff. Emergency situations in school must receive instant response; followed by immediate transfer to hospital where senior medical staff will become responsible for the child and with the parents will make the necessary decisions.

The Policy that we assume that events in Ysgol Grug and elsewhere in Wales will be measured by is "Decisions Relating to Cardiopulmonary Resuscitation", the Joint Statement issued by the BMA, the RCN and the Resuscitation Council (UK) (1999). Let us be quite clear that DNR orders are totally unacceptable in a school setting. However the Head Teacher at Ysgol Crug Glas supported by senior Officers of the LEA were actively seeking such orders in the Pinnington case.

A letter from the BMA to the Davies’ says, “It was not the BMA’s intention that its DNR policy note should be applied outside the in-patient hospital setting”. In the case of a child we would consider it obligatory that parents/carers of children have their consent sort prior to any change in any care plan. Such consultation is in line with the partnership principle in the Children’s Act 1989, and failure to adhere to such consultation and seeking consent could expose the care agency to subsequent action by carers on behalf of their child. It is vital the above intention from the BMA is adhered to throughout Wales and again we stress that in relation to medical issues in particular, for all children consultation with the parents/carers must be obligatory.

The Kennedy Report into Bristol Royal Infirmary has been particularly critical of poor communication between parents and staff, contributing to the deaths of babies, "The sense is gained that informing parents and gaining their consent to treatment was regarded as something of a chore." In the Pinnington Case, there was no consultation and the initiator of the DNR was not qualified either!

3. Clinical and Line Management Supervision.

Where medical staff work in non-medical settings and may be supervised by Managers who are not medically qualified, arrangements should be in place that the medical staff receive professional and clinical supervision from a senior medically qualified person who may work elsewhere; for instance, in Bunny Pinnington's case she should have had regular clinical supervision perhaps from a Senior Community Nurse experienced in learning and other disabilities.

However, there was some evidence in the Pinnington Case of subsequent collusion between medical and education senior staff endeavouring to suppress her and the embarassment she was causing various members of the "great and the good" in Swansea and the Assembly, perhaps a reflection of a wider "club culture" in Wales, resonant of the one Professor Kennedy describes in Bristol. Only major cultural changes at the most senior level could address this and Freedom to Care has little evidence that the Assembly, whose responsibilty it would be to lead such change, has the will to address these issues on behalf of vulnerable children.

4. Public Interest Disclosure ("whistleblowing").

Whistleblowing Procedures must be in place in all settings and be available to staff and not subject to senior management decisions to pre-empt access to the Procedure by raising other matters. The availability of a Whistleblowing Procedure in each setting should be one of the measures included in the National Standards for Children's Health Services due to be published by the new National Director of Children's Health Services, Professor Aynsley-Green. Also, the recommendations of the Study need to be considered for inclusion in the Special Educational Needs Draft Code of Practice, currently before Parliament.

Whistleblowers must have immunity from disciplinary action to silence them raising their concerns and discourage others coming forward to disclose harm and malpractice to children.

In addition, to enhance a growth away from the "blame culture", where staff commit acts of negligence through error (rather than through provable deliberate malpractice), they should have immunity from discipline and instead the matters dealt with via performance review; this will encourage discussion and debate about failures of practice and may correct the defensive cultures that seek to identify individuals to blame and encourage mutually litiginous postures. This may enhance understanding errors through peer debate to improve future outcomes for patients/clients/students.

Parents, staff and others advocating on behalf of vulnerable children should be made aware of how to access the powers of Peter Clarke, the Commissioner for Children, Wales, if required. The Assembly may also have to review the powers of Mr. Clarke in the light of discussions in England on a Commissioner there with wider powers.

5. Summary.

As we outlined above, the outcomes of this Study cannot be simply procedural; the ongoing failures to adequately protect children in some settings in Wales and the persistent harassment of those raising just concerns and advocating on behalf of those children, show clearly that the solution lies in changing organisational cultures and the leadership of those who set those cultures. At the summit of this process must be the Assembly Members and their Officers themselves. It is a challenge for them and frequently they will have to put the interests of vulnerable children before the interests of party loyalty. If they cannot do that at the National level in Wales, what hope have they of setting an example to local Councillors and Officers in the way that they deal with the embarrassments of incidents of institutional harm to children?

_____________________________

6. Recommendations

6.1. DNR orders are not acceptable for a school.

6.2. Should a child collapse in school, emergency resuscitation procedures should be carried out immediately and the child transferred to hospital where senior medial staff assume responsibility for the child.

6.3. Care plans must address all areas of care for the individual and where medical issues are addressed it must be drawn up, monitored and updated by medical personnel only, in consultation with parents.

6.4. Where medical staff work in non-medical settings and may be supervised by Managers who are not medically qualified, arrangements should be in place that the medical staff receive professional and clinical supervision from a senior medically qualified person.

6.5. The availability of a Whistleblowing Procedure in each setting should be one of the measures included in the National Standards for Children's Health Services

6.6. Whistleblowers must have immunity from disciplinary action to silence them raising their concerns.

6.7. Where staff commit acts of negligence through error (rather than through provable deliberate malpractice), they should have immunity from discipline and instead have the matters dealt with via performance review.

6.8. Parents, staff and others advocating on behalf of vulnerable children should be made aware of how to access the powers of the Commissioner for Children, Wales.

6.9. The Assembly may also have to review the powers of the Commissioner for Children, Wales in the light of discussions in England on a Commissioner there with wider powers.

Chris Clode,

for Freedom to Care (28/7/01).

NEWS UPDATE 3rd July 2002

BUNNY PINNINGTON - the Nurse who blew the whistle to save a life

Bunny, the school nurse in South Wales who in 1996 was requested to delay the resuscitation of a child in her care with serious disabilities, and was harassed from her job, when she refused the instruction, is at last in her 5 day Employment Tribunal Hearing in Cardiff. Bunny and her husband have battled on for this with Freedom to Care's support, despite her union the Royal College of Nursing [RCN] ceasing to support her.

Bunny Pinnington was the Nurse at Ysgol y Grug, a Swansea Special School for children with profound disabilities for six years. In 1996, she was given by her (non-medically-qualified) Head Teacher a Do-Not-Resuscitate instruction on child A and another child. This was done against the opinion of Anna’s consultant and without any consultation with the carers. Since then, she has been effectively driven from her job following her refusal to accept the Head Teacher’s instruction.

The RCN they no longer support Bunny’s case. She, meanwhile has struggled on to pursue this important case of principle at her own expense, but with the continued support of A’s carers, her grandparents. They have said, “Bunny has lost everything through standing up for her principles. She is fantastic. A is a very happy child. She cannot move but she smiles and is very rarely ill. If she collapsed, we would expect the nurse to give her mouth to mouth [resuscitation].”

The RCN made a joint statement with the BMA and the Resuscitation Council (UK) in June 1999; Bunny’s case represents clear breaches of this in that “responsibility for a DNR [Do Not Resuscitate] decision rests with the consultant or general practitioner in charge of the patient’s care” (para. 3) and that “Relatives and others close to the patient should be assured that their views on what the patient would have wanted will be taken into account in decision making.” (para. 9). This is a critical issue, especially for those medically qualified staff who work outside wholly medical settings and may have non-medical managers impinging on medical decision-making and diagnosis. It was as a result of Bunny's case that the Welsh Assembly set up an all-Wales Study of Do Not Resuscitate (DNR) Orders in Schools- but the Assembly refused to take up the issue of her losing her job through whistleblowing on behalf of the life of a child.

Freedom to Care has been involved in advocating on behalf of Bunny and the rights of the child and her carers in these matters. We have given support not just because of the injustices we believe they have suffered in these events; we are also concerned about:

1. the flouting of agreed procedures put in place to protect vulnerable children,

2. the harassment and denial of due process to those seeking to raise concerns on behalf of those children.

These are the same issues that were central to the Waterhouse Report, “Lost in Care”; although the child concerned was not in Local Authority care, the risks to her, following the DNR instruction from a medically unqualified Head Teacher, were of denial of life. Even most of the Waterhouse victim-witnesses were not threatened to the extent of the child in this case, yet the qualified professional challenging the instruction was marginalised and finally disposed of in a similar way to Alison Taylor and other witnesses in North Wales.

Does it have to take the loss of a School Nurse's job to ensure that the Assembly for Wales listens to those advocating for the safe care of our most vulnerable children?

Chris Clode, National Coordinator, Freedom to Care. 30/7/02.

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