A rest home nurse who failed to give a resident CPR as they choked to death breached the Code of Health and Disability Services.
On Monday, Deputy Health and Disability Commissioner Rose Wall released a report into the 85-year-old woman's death.
She was discovered choking on mashed potato at lunchtime in the dining hall of her rest home. The caregiver who realised the situation called a nurse for assistance.
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The report says the nurse found the woman unresponsive with no pulse and no signs of breathing. While telling another nurse to call 111, she gave the woman four "hard" back slaps in an attempt to dislodge the food.
When that proved ineffective, the nurse moved the woman out of the room and onto the floor a short distance outside the dining hall door. She later told the woman's daughter that she did so to "preserve her dignity", but has since claimed there were other factors at play such as the limited floor space in the dining hall.
After lowering the woman to the floor, the nurse checked for signs of life once more. She made no further attempts to administer CPR while waiting for paramedics, the report found.
When paramedics arrived, they discovered the mashed potato blocking the woman's airway and pronounced her dead.
In the report, Wall criticised the nurse for not urgently beginning CPR as soon as the woman was judged unresponsive. She acknowledged that soft mashed potato would probably not have been successfully dislodged by chest compressions, but said the nurse failed to provide reasonable care by not continuing CPR procedure.
Wall also said the nurse's decision to move the woman to another room wasted valuable time. She recommended the nurse give the woman's family a written apology for her breach of the Code, and that her emergency responses be reviewed.
Wall also recommended the rest home develop a system to monitor staff's compliance with life support training and send all staff involved in the choking incident to a first aid course.
The New Zealand Resuscitation Council's guidelines to preventing choking death recommend giving the afflicted person five back blows followed by five chest compressions, and should be repeated until either the blockage is dislodged or the person loses consciousness, at which point CPR should be commenced.
At the time of the incident, the unnamed rest home had no official choking policy but has developed one since then.