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Nurse handed caution for not carrying out CPR on 'clearly dead patient'

  • 40 Comments

An experienced nurse has received a 24-month caution after failing to give cardiopulmonary resuscitation to a care home patient “who was almost cold” when she arrived on the scene.

A Nursing and Midwifery Council conduct and competence committee issued the caution last month, after a hearing concluded that she had been at fault during the incident.

“A caution order may be appropriate where the case is at the lower end of impaired fitness to practise”

NMC case notes

Jane Frances Kendall admitted that her fitness to practise was impaired as a result of her misconduct for failing to attempt CPR or ensure that emergency services were contacted.

The incident occurred on 26 November 2014 at Moorland Nursing Home in Poulton-le-Fylde, Lancashire, where Ms Kendall was employed.

According to the NMC case notes, a resident was found to be unresponsive by a care assistant, who called Ms Kendall to attend, as she was the nurse in charge at the home on the date of the incident.

When Ms Kendall attended, she found the resident to be “waxy, yellow and almost cold”, NMC the case notes said.

They added that Ms Kendall stated that the “resident was not breathing and having checked the resident, found that there was no pulse or vital signs of life”.

The regulator noted that Ms Kendall admitted that she subsequently failed to attempt CPR or call the emergency services.

The resident did not have a DNAR (Do Not Attempt Resuscitation order) in place and was in fact, certified dead later that day by paramedics, said the NMC.

“When Ms Kendall attended, she found the resident to be ‘waxy, yellow and almost cold’”

NMC case notes

A subsequent police investigation concluded there was nothing suspicious about the resident’s death and the coroner determined that, while it was unexpected, she died from natural causes.

Ms Kendall had worked for the home since 2007 and had extensive nursing experience, having joined the register in 1973. She was also in charge of the home when its manager was not on shift.

Following the incident, the home conducted an internal investigation and Ms Kendall was suspended. The home later lifted the suspension and issued her with a final written warning.

Ms Kendall said she admitted that her standard of care on that occasion, fell short of what would be expected of a registered nurse in those particular circumstances.

She admitted that, although she considered the resident had already died, as no DNAR was in place and the resident’s death was unexpected, she was under an obligation to attempt CPR and to call for emergency assistance.

Furthermore, she admitted that she was acting outside of her competence on the occasion in question and was not qualified to certify death.

In a letter to the NMC, Ms Kendall said she had reflected since the incident and that, faced with a similar situation, she would conduct CPR and would call the emergency services.

“The resident did not have a DNAR in place and was in fact, certified dead later that day by paramedics”

NMC case notes

Ms Kendall further stated that she was “very remorseful regarding the incident and reiterates the steps that she would take, faced with a similar situation”, said the NMC case notes.

In addition, the NMC acknowledged that Ms Kendall had undertaken re-training to address the deficiencies in her practice and to update her knowledge.

It also highlighted that she was still worked at the home where the incident occurred and that her employers had no concerns and felt she was a good employee, who worked in line with her job description.

The NMC concluded that, although Ms Kendall had been working without further concern since the incident, there was a small risk of repetition in the case, though there had not been once as yet.

“The appropriate sanction in this case, therefore, is a caution order for a period of 24 months,” said the regulator.

“The indicative sanctions guidance states that a caution order may be appropriate where the case is at the lower end of impaired fitness to practise and the panel wish to mark the registrant’s behaviour as unacceptable and should not happen again,” it added.

Ms Kendall did not attend the hearing in London.

  • 40 Comments

Readers' comments (40)

  • If a qualified person is prepared to say a patient is dead and cold with no vital signs of life then there should be no obligation to perform CPR on a dead body. An arrest or actively dying patient is different. They are accountable after all.

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  • Really surprised you make no reference to the back that the nurse was acting in accordance with the Resus Council/BMA/RCN guidance and that the FtP panel did not use any up to date guidance. Also that the panel doesn't appear to understand the difference between diagnosing death (a clinical job) and certifying death (a legal responsibility). Nurse can't adn don't need to certify death but they can diagnose death and act in accordance with best practice guidance.
    I am ashamed to be a nurse when I look at the NMC action

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  • As I understand it there is no obligation for health professionals to perform CPR on a deceased person or if they have reason to believe it would be futile. Registered nurses should be supported in their decision unless the NMC wishes to deligitimise an RNs ability to recognise death, a "skill" that any member of the general public has. I use the phrase "recognise death" very carefully, something that is quite different to verifying death (done later here by the paramedic) or certifying death (something only a medical practitioner can perform) and the ruling has not been distinct enough in its choice of language.
    It was later confirmed that the lady in question died of natural causes and it is questionable whether her death would've been entirely unexpected.
    The RN clearly does not dispute the chain of events, it is in my mind unfortunate that these actions have been ruled as below the acceptable standard of practice rather than an act of compassionate care of the dying.
    To that end this ruling has far reaching consequences for RNs would benefit for some clarity around these issues.

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  • As a student I witnessed a 92 year old woman having CPR due to no DNAR in place. On talking to her relatives they hoped she had passed away peacefully unaware of the preceding events. The patient had no DNAR due to an oversight, she was also cold to touch and 'had' passed peacefully. On another occasion I held an 90 year old lady's hand as she peacefully passed on, a completely different emotion.

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  • Absolute disgrace that the NMC wasted our money on terrorizing this nurse (and I do not use that term lightly.) I agree with the above comments completely and wish she had been there when my own Mother was dying.

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  • As above. The NMC does terrorize nurses.
    Its a shame nurses are not good at supporting each other and acting together.
    There should be a mass refusal to pay NMC fees.
    So we all now have to try to resuscitate a dead person or face the wrath of the NMC.

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  • I find this situation really sad - this nurse has obviously had years of experience and through this was able to recognize that this person had died some time before as we read the person was “waxy, yellow and almost cold”. To attempt CPR in this instance would have had no benefit at all - and would have offered no dignity for this person who had died from natural causes.

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  • Nmc be ashamed of yourself no wonder nurses leaving in disgust of the way they are treated,that nurse obviously cared for that patient what about dignity for the patient,if that nurse had started cpr on any of my relatives in a nursing home I would think it was an assault if anything.

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  • Nmc be ashamed of yourself no wonder nurses leaving in disgust of the way they are treated,that nurse obviously cared for that patient

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  • I can't believe I have just read this. Surely it is not right to try and resuscitate a patient who has so obviously died of natural causes. I am not sure how old the resident was but because you are a resident in a care home does this mean before you are accepted you better not think of dying there and if you are then you better do it somewhere else!

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