The Health & Disability Commissioner has found that a registered nurse breached the Code of Patients’ Rights after she failed to carry out CPR on a choking patient.  The patient was in a rest home and was discovered choking while have a meal.  A care giver administered back slaps before the registered nurse took over his care.  The registered nurse checked for signs of breathing and pulse and arranged for the ambulance to be called and administered four hard back slaps.  These were ineffective. 

The nurse lowered the patient to the floor, but made no attempt to perform CPR while waiting for the ambulance to arrive.  The paramedics on arrival found that the patient’s airway was blocked with food and the patient was pronounced dead.

The Health & Disability Commissioner found that failing to commence CPR meant the nurse failed to act with reasonable care and skill and breached the Code of Patient Rights.  She was also criticised for her incomplete documentation of the event, as well as her inadequate communication with the family after the patient’s death.  She was to apologise to the patient’s family and the Commissioner recommended that the Nursing Council undertake a competency review of her emergency response.

The rest home was to send staff involved in this incident to a Level 2 course on CPR.


Alan Knowsley
Medical Lawyer
Wellington