Robert Murray

Unit 56, Innovation Centre,  
Highfield Drive, 
St Leonards-on-Sea, East Sussex, TN38 9UH. 
Email: 
Telephone: 

16th June 2022. 

Dear Mr Craze, 

RESPONSE: Robert-Murray-Prevention-of-future-deaths-report-2022-0093 

Thank you for extending the response time to 23rd June 2022. 

A planning meeting was held on 7th June to discuss concerns from your report and actions in place by 
Avalon Nursing Home to prevent future deaths. This meeting was attended by representatives from 
Adult Social Care (ESCC), Care Quality Commission, ESCC Market Support and Registered Manager 
from Avalon Nursing Home. 

It was mentioned at the planning meeting that you had already held a Pre-Inquest Review (PIR) 
meeting with Avalon on 18th November 2021 and advice related to DNACPR and RESPECT forms had 
been updated and included in all care plans, where necessary. Avalon also held a discussion with 
local surgery, Park Practice and Paramedic Practitioners regarding clinical judgements related to 
RESPECT and DNACPR initiations. 

All Staff attended refresher trainings on Basic Life support, 27th July and 14th October 2021. Senior 
care staff had extra training on First Aid to boost confidence on when to initiate CPR, whilst waiting 
for a nurse to attend. Other activity staff, including kitchen and housekeeping took courses on 
Emergency First Aid at Work on 18th May 2022.  

The managers attended CPR sessions by St Johns Ambulance on behalf of ‘Restart a heart day’ on 
the 14th of October 2021 and 18th of February 2022.  

Avalon also made changes to their policy on ‘Calling an ambulance’ and DNACPR (see attached) to 
reflect current and ongoing practice learning.  

Representatives from Market Support and CQC have considered the report in their commissioned 
inspections and ongoing monitoring of quality of services and support. 

Avalon will ensure learning from this experience remain an ongoing conversation in supervision and 
as part of their internal monitoring of quality of service. 

Please feel free to contact me to discuss any other support necessary. 

Thank you. 

Kind Regards 

Senior Practitioner Social Worker (Duty) 
& Best Interest Assessor (DOLS) 

 
 
 
 
 
  
 
 Neighbourhood Support Team, Eastbourne & South Wealden. 
6th Floor, St Mary’s House  
52 St. Leonards Road  
Eastbourne  
East Sussex  
BN21 3UU  

Tel: 
Email: 

Documents attached:  
1.  Avalon Calling an ambulance (999) Policy 
2.  Avalon DNAR and CPR policy

From the Chief Executive and Registrar 

Mr Alan Romilly Craze 
HM Senior Coroner for the Coroner area of East Sussex 

18 May 2022 

Dear Mr Craze 

Prevention of Future Deaths Report following the Inquest into the death of the 
late Robert George Murray  

Thank you for sharing your Prevention of Future Deaths Report (which I refer to as the 
‘Report’), and for giving us an opportunity to respond to the important concerns that you 
have raised.  

Before I address the concerns in your Report, I would like to extend my deepest 
sympathy to Mr Murray’s family and friends.   

In your Report you identified the following as a matter of concern: 

“From listening to the 999 call between the registered nurse at the care home and the 
call operator, and also from evidence heard at the inquest, it is apparent that no one 
involved understood that there are circumstances when the DNACPR should not be 
applied. I am concerned that this may potentially be an issue elsewhere in the country 
and further training and clarification is therefore necessary.” 

You have asked us to respond to this concern and have specifically identified further 
training and clarification about the circumstances in which DNACPR (Do Not Attempt 
Cardiopulmonary Resuscitation) notices should not be applied is necessary across the 
country. 

I would like to provide you with some assurance about how our standards of proficiency 
for registered nurses, our Code1 and our revalidation process2 require registered nurses 

1 A link to our Code: https://www.nmc.org.uk/standards/code/  
2 A link to our Revalidation information: https://www.nmc.org.uk/revalidation/  

 
 
 
  
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 to understand the requirements of DNACPR notices. This letter therefore provides 
information about: 

•  Our role as a regulator and how we set and maintain the standards of education 

and training to ensure safe, effective and kind nursing care.  

•  Our standards of proficiency (which all nurses must meet to be able to join our 
register), which includes specific standards that relate to the knowledge, skills 
and experience that a registered nurse must have about end of life care and 
DNACPRs.  

•  The requirements of registered professionals throughout their practice including 
an explanation of how, once a registered nurse has joined our register, they are 
expected to maintain their knowledge and skills in line with their scope of 
practice, in accordance with our Code and through our revalidation process.  

Our role 

Our vision is safe, effective and kind nursing and midwifery that improves everyone’s 
health and wellbeing. As the professional regulator of almost 745,000 nursing and 
midwifery professionals, we have an important role to play in making this a reality. 

Our core role is to regulate. First, we promote high education and professional 
standards for nurses and midwives across the UK, and nursing associates in England. 
Second, we maintain the register of professionals eligible to practise. Third, we 
investigate concerns about nurses, midwives and nursing associates. We believe in 
giving professionals the chance to address concerns, but we’ll always take action when 
needed. 

Our role in undergraduate education for nursing professionals 

Nurses who wish to practise in the UK must be registered with us. Those who apply to 
be registered with us must meet the standards of proficiency3 necessary for safe and 
effective practice and additional requirements for registration, for example our health 
and character requirements. 

Nursing and midwifery professionals can demonstrate that they have met these 
standards of proficiency by completing approved qualifications as part of a pre-
registration education programmes that have been approved by us in the UK. We set 
wider standards for nursing and midwifery education and programme standards4 which 
enable our approved education institutions to deliver programmes related to the relevant 
standards of proficiency. The approved education institutions will design their 
curriculums to be able to meet our standards. We approve programmes and monitor the 
education institutions and their programme delivery as part of our Quality Assurance 

3 The standards of proficiency for registered nurses can be found here: 
https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-nurses/  
4 Our standards for education and training can be found here: https://www.nmc.org.uk/standards-for-
education-and-training/ and our standards for pre-registration nursing programmes can be found here: 
https://www.nmc.org.uk/standards/standards-for-nurses/standards-for-pre-registration-nursing-
programmes/  

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 activities. Our responsibilities and powers are set out in the Nursing and Midwifery 
Order 2001 and accompanying Privy Council Orders and Rules5. We explain below how 
our standards of proficiency for registered nurses and the standards within our Code 
address the concerns you have raised in your Report. 

Future Nurse: Standards of Proficiency for registered nurses 

In 2016 we embarked on a significant programme of change in relation to all of our 
education and training standards, which has included revising our standards of 
proficiency for registered nurses and midwives to strengthen public protection and 
continue to make sure that they are fit for purpose.  We introduced new standards of 
proficiency for registered nurses in 2018 (described as the Future Nurse standards6).  

The Future Nurse standards were approved by our Council following extensive 
consultation and engagement over a two year period. All pre-registration programmes in 
the UK have been approved against the new Future Nurse standards. We expect the 
first nurses will graduate under these new standards in 2022.  

Future Nurse: Standards of Proficiencies relevant to end of life care and 
DNACPRs 

In our Future Nurse Standards, we include proficiencies that relate to the person–
centred care and decision-making for people at the end of life and the involvement, 
support and care of their families. The following standards are relevant: 

“At the point of registration, a registered nurse must be able to:  

3.14 identify and assess the needs of people and families for care at the end of 
life, including requirements for palliative care and decision making related to their 
treatment and care preferences 

3.15 demonstrate the ability to work in partnership with people, families and 
carers to continuously monitor, evaluate and reassess the effectiveness of all 
agreed nursing care plans and care, sharing decision making and readjusting 
agreed goals, documenting progress and decisions made, and 

3.16 demonstrate knowledge of when and how to refer people safely to other 
professionals or services for clinical intervention or support… 

…4.9 demonstrate the knowledge and skills required to prioritise what is 
important to people and their families when providing evidence-based person-
centred nursing care at end of life including the care of people who are dying, 
families, the deceased and the bereaved 

4.10 demonstrate the knowledge and ability to respond proactively and promptly 
to signs of deterioration or distress in mental, physical, cognitive and behavioural 
health and use this knowledge to make sound clinical decisions.” 

5 Details about the legislation that governs us can be found here: https://www.nmc.org.uk/about-
us/governance/our-legal-framework/our-order-and-rules/  
6 ‘Future Nurse: standards of proficiency’, published May 2018 
https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-nurses/  

Page 3 of 6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Future Nurse Standards includes communication and relationship management 
skills and nursing procedures that at the point of registration, a registered nurse will be 
able to do. The relevant sections related to end of life care and use of DNACPRs is 
below: 

“10. Use evidence-based, best practice approaches for meeting needs for care 
and support at the end of life, accurately assessing the person’s capacity for 
independence and self-care and initiating appropriate interventions 

10.1 observe, and assess the need for intervention for people, families and 
carers, identify, assess and respond appropriately to uncontrolled symptoms and 
signs of distress including pain, nausea, thirst, constipation, restlessness, 
agitation, anxiety and depression 

10.2 manage and monitor effectiveness of symptom relief medication, infusion 
pumps and other devices 

10.3 assess and review preferences and care priorities of the dying person and 
their family and carers 

10.4 understand and apply organ and tissue donation protocols, advanced 
planning decisions, living wills and health and lasting powers of attorney for 
health 

10.5 understand and apply DNACPR (do not attempt cardiopulmonary 
resuscitation) decisions and verification of expected death 10.6 provide care for 
the deceased person and the bereaved respecting cultural requirements and 
protocols.” 

(Excerpt from Annexe B: Nursing Procedures, Future Nurse: Standards of Proficiency) 

Education institutions are expected to ensure the curriculum they design allow the 
students to achieve the above standards of proficiency. We therefore expect registered 
nurses at the point of registration to have the knowledge and skills of DNACPRs as part 
of their pre-registration education.   

Our Code 

I note that you have not specifically asked about our Code and have focussed on our 
education standards. However, I think it is helpful to understand our expectations 
regarding the standards and behaviours for nurses who have entered our register and 
what we would expect that a nurse who was involved in Mr Murray’s care should 
consider.   

Once admitted to our register, professionals are required to meet the requirements of 
our Code7. The Code details professional practice and behaviours that all of our 

7 https://www.nmc.org.uk/standards/code/read-the-code-online/  

Page 4 of 6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 professionals must meet and reflect upon as part of their revalidation and renewal of 
their registration every three years8.  

The Code requires nurses and midwifery professionals to prioritise people and the 
decisions they make in relation to their care, make timely referrals when there is a 
worsening condition and act within the relevant policies about protecting and caring for 
vulnerable people. I highlight the following sections of the Code: 

“1.1 treat people with kindness, respect and compassion … 

..2.5 respect, support and document a person’s right to accept or refuse care and 
treatment 

6 Always practise in line with the best available evidence  
…6.2 maintain the knowledge and skills you need for safe and effective practice 

…13.1 accurately identify, observe and assess signs of normal or worsening 
physical and mental health in the person receiving care  

13.2 make a timely referral to another practitioner when any action, care or 
treatment is required 

13.3 ask for help from a suitably qualified and experienced professional to carry 
out any action or procedure that is beyond the limits of your competence… 

…15.1 only act in an emergency within the limits of your knowledge and 
competence  

…15.2 arrange, wherever possible, for emergency care to be accessed and 
provided promptly 

…17.3 have knowledge of and keep to the relevant laws and policies about 
protecting and caring for vulnerable people” 

We recognise that nurses use their professional judgement with reference to the 
relevant provisions of the Code (outlined above) to make decisions based on evidence 
and often in difficult and complex situations. The Code supports their professional 
practice and on the rare occasions when things go wrong, they are expected to be open 
and honest (the duty of candour9) and reflect on what they do well and what they can do 
better and how they learn from their mistakes.   

Employers also play an important role in ensuring that the nurses they employ 
understand local policies and procedures, and support the development of the 
professionals they employ.  

In some instances, a nurse’s conduct may result in a fitness to practise referral. Where 
a concern is raised about a nurse’s fitness to practise, we determine whether their skills, 

8 Article 10 of the Nursing and Midwifery Order 2001 
9 A link to our joint guidance with the General Medical Council on the duty of candour: 
https://www.nmc.org.uk/standards/guidance/the-professional-duty-of-candour/  

Page 5 of 6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 knowledge, education or behaviour fall below the standards needed to deliver safe, 
effective and kind care. Fitness to practise cases can include allegations about 
misconduct (where a professional’s conduct may fall seriously short of the expectations 
in the Code) or lack of competence (which would usually involve an unacceptably low 
standard of professional performance). We also take account of the context in which the 
nurse, midwife or nursing associate was practising when deciding whether there is a 
risk to patient safety that requires us to take regulatory action. We believe in giving 
professionals the chance to address concerns about their fitness to practise, but we will 
always take regulatory action where appropriate. This can include removing people from 
our register in the most serious cases10. 

Furthermore as part of their revalidation, nurses on our register are required to meet 
standards of continuing professional development which include education, training and 
reflection against their scope of practice. Revalidation is something that nursing and 
midwifery professionals must do every three years, and is necessary to maintain their 
registration.  

Further information 

I note that you have not raised any specific concerns about specific nurses in your 
report.  If you do have any concerns about an individual’s fitness to practise, please let 
us know.  

I hope this letter provides you with information about our nursing standards and the 
steps and the work we do to minimise the risk of deaths occurring as a result of any 
potential gaps in the knowledge and skills for registered nurses, midwives and nursing 
associates.  

Once more I would like to offer my deepest sympathy to Mr Murray’s family and friends.  

Yours sincerely 

Executive and Registrar 

10 An overview of our fitness to practise process can be found here: https://www.nmc.org.uk/concerns-
nurses-midwives/what-is-fitness-to-practise/an-introduction-to-fitness-to-practise/  

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