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.