Background In 2015, an ‘All Wales’ DNACPR policy was implemented with the intention of providing consistency and continuation of DNACPR decision making throughout all health care settings within Wales. The aim of the audit was to investigate the use of this policy within a SPCU in Swansea against audit standards outlined in the All Wales DNACPR guidance.

Methods A case note analysis of all patients who died in or were discharged from the SPCU during two 8 week periods between August 2015 and May 2016 was performed. The audit measures included accurate DNACPR form completion, time taken to senior review and wider communication of the DNACPR decision. The audit standard for each measure was 100%. Changes introduced following the first audit included formalisation of the ward clerk role in coordinating DNACPR forms on discharge and use of the handover list to prompt DNACPR form distribution.

Results Adequate completion of DNACPR forms improved from 44% to 89% between the two audit periods. Senior review of this decision improved from 81% to 96%, although mean time to review increased from 1.2 days to 3.8 days. Communication of the DNACPR decision to the GP increased from 77% to 91% and communication to the out-of-hours GP increased from 11% to 73%.

Conclusions This is, to the author’s knowledge, the first complete audit cycle in relation to the new All Wales DNACPR policy. Whilst significant improvement was made during completion of the audit cycle further improvements are required to reach the audit standard. Future recommendations include modifying the ward discharge ‘check-list’ to include the DNACPR form. The audit highlights the challenges of ensuring thorough documentation and dissemination of DNACPR decisions. These results have been shared with the national DNACPR audit which will hopefully influence further evolution of the current policy.