An elderly rest home resident who was choking on mashed potato died without the nurse who responded to her attempting CPR, the Health and Disability Commission has found.

Deputy commissioner Rose Wall today released a report finding the nurse had breached the 85-year-old's right to reasonable care under the Code of Health and Disability Services.

The nurse was called to assist a caregiver when the 85-year-old woman was found choking in the rest home dining hall, the HDC said. The woman was found unresponsive, with no signs of breathing and no radial pulse.

The nurse told another nurse to call 111 and administered four hard back slaps. After that didn't work she moved the woman out of the dining room to an area where there was more space, laying her on the floor and again checking for signs of life. She made no attempt to perform CPR while waiting for the ambulance.


Paramedics arrived and found mashed potato blocking the woman's airway. The woman had no pulse and was pronounced dead.

Wall criticised the nurse for failing to start CPR urgently. She acknowledged the potato was unlikely to have been dislodged by chest compressions, but said starting CPR would still be considered reasonable care.

The HDC found the nurse should have moved the woman to the dining room floor rather than spend time getting her to another room - estimated to have caused a 15-30 second delay.

The nurse said she had moved the woman primarily because there was limited space in the dining room, and to improve access for ambulance staff.

The deputy commissioner recommended the nurse write an apology to the woman's family for breaching the Code - although she made it clear that the nurse following correct procedure would not be likely to have saved the woman's life.

She also recommended that the Nursing Council of New Zealand review the nurse's emergency response competency, and that the rest home develop a system to monitor whether non-clinical staff had basic life-support training. All staff involved in this event were to be sent to a full first aid/CPR Level 2 course.

The rest home has since developed a choking policy, which states if a patient is responsive, the staff member is to administer five back blows, alternating with five chest thrusts.

If the patient is unconscious the staff member is to continue with CPR until the ambulance arrives.