HCJ-wide point prevalence audit

​​​Request 719459666

1. Please provide a copy of the HCJ-wide point prevalence audit on compliance with DNACPR documentation that was commissioned by the Serious Incident Review Panel.

2. Please also provide a copy of the audit of DNACPR forms in the Hospital that was carried out as a result of this.

Response

A Health and Care Jersey (HCJ) point-prevalence audit on compliance with DNACPR inpatient documentation was undertaken in June 2024 to identify opportunities for learning, and was presented to the Serious Incident Review Panel in the attached ‘Review of current DNACPR orders of current inpatients’.

Conducting such audits reflects national good practice and is consistent with the published Jersey Multi-agency Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policy Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policy​.

 Freedom of Information response 719459666 - Attachment 1.pdf​

As a result of this report from last year, a number of actions were identified and put in place at the time; amongst these, the Law Officers’ Department were invited to assist by delivering legal training on DNACPR, which has since been reinforced at INSET days (essential training days for clinical staff). A further review of training is planned for September / October 2025.

The Action Log detailing each recommended action and the status is attached. Personal identifiers of employees in roles below Tier 2 have been redacted to protect individual privacy. Article 25 of the Freedom of Information (Jersey) Law 2011 has been applied.

Freedom of Information response 719459666 - Attachment 2.pdf​

Ongoing audit of DNACPR documentation is undertaken by clinical staff, with 2025 results as follows:

Quarter 1: 93% of DNACPR forms signed by Consultant

Quarter 2: 98.3% of DNACPR forms signed by Consultant.

Article applied

Article 25 - Personal information

(1) Information is absolutely exempt information if it constitutes personal data of which the applicant is the data subject as defined in the Data Protection (Jersey) Law 2018.

(2) Information is absolutely exempt information if –

(a) it constitutes personal data of which the applicant is not the data subject as defined in the Data Protection (Jersey) Law 2018; and

(b) its supply to a member of the public would contravene any of the data protection principles, as defined in that Law.​​​​