Deputy Health and Disability Commissioner Rose Wall today released a report finding a nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for a failure relating to the resuscitation of an 85-year-old woman who was resident in a rest home.
The nurse was called to assist a caregiver when the woman was discovered choking in the rest home dining hall. The nurse found the woman 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.
When the back slaps proved to be ineffective, the nurse moved the woman from the dining room and lowered her onto the floor, and again checked for a pulse and any signs of breathing. The nurse made no attempt to perform CPR while waiting for the ambulance to arrive. 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 criticised the nurse for failing to start CPR urgently as soon as the woman was first assessed to be non-responsive. 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.
The full report for case 17HDC01484 is available on the HDC website.