Rest home nurse breached code of rights after failing to perform CPR on patient who died of choking

A registered nurse who found an 85-year-old rest home resident had choked has breached the Code of Health and Disability Services Consumers’ Rights by failing to administer CPR, according to a report following the incident.

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In 2017, the resident was discovered choking in the dining room of the rest home by a caregiver, who administered two back slaps before the Registered Nurse (RN) took charge.

The RN found the resident to be unresponsive, with no signs of breathing and no radial pulse. She instructed another nurse to call 111, and administered four hard back slaps.

Deputy Health and Disability Commissioner (HDC), Rose Wall today released the report of the finding and found the nurse to have been in breach of the code.

Expert advisor, RN Megan Sendall, noted that the New Zealand Resuscitation Council (NZRC) Guidelines related to choking require a responder to administer CPR if the patient loses consciousness.

The report noted five minutes had elapsed from the time of calling the ambulance, to the time of its arrival, during which time RN should have commenced CPR.

When the paramedics arrived they found mashed potato blocking the woman’s airway. No pulse could be found, and subsequently the woman was pronounced dead.

Ms Wall acknowledged that the particular obstruction was unlikely to have been dislodged via chest compressions, but considered that reasonable care would have been to commence CPR.

Ms Wall recommended that the nurse provide a written apology to the woman’s family for her breach of the Code.

She also recommended that the Nursing Council of New Zealand undertake a competency review of the nurse’s emergency responses, and that the rest home develop a system for monitoring non-clinical staff compliance with basic life-support training, and send all staff involved in this event to a full first aid/CPR Level 2 course.