Blog: Reflections on recent CPR fitness to practise case

As the professional regulator for nurses and midwives in the UK and nursing associates in England, the Nursing and Midwifery Council (NMC) has an important role in protecting the public, including reviewing concerns about our registrants when they are referred to us.

Our fitness to practise hearings are, in the main, held in public and the decisions made by our panels are publicly available documents. I welcome the scrutiny of our process and decisions this brings, and in particular welcome the desire of professionals to learn lessons from specific cases to inform their own future practice and prevent similar issues occurring. 

Key points

Concerns have been raised about the decision made by an NMC Fitness to Practise panel in respect of Mrs Nahid Nasiri. In this blog I will summarise the situation and share the lessons I believe this case highlights.

I’d like to begin by clarifying the NMC fully supports best practice guidance. This emphasises that there’s a presumption in favour of commencing cardiopulmonary resuscitation (CPR) when there is no Do Not Attempt CPR (DNACPR) in place. However, professionals can depart from this on the basis of careful, considered clinical decision making. 

The NMC panel did not find any evidence of the careful, considered judgment expected in the guidance when Mrs Nasiri failed to perform CPR. This is why the sanction of a 12 month suspension from the register was imposed.

The decision made by the panel in this case is still subject to appeal. I will therefore be careful to confine my comments to clarifying some of the issues that have been the subject of much debate so as not to compromise any appeal that Mrs Nasiri may wish to bring. While the panel decision makes it clear that Mrs Nasiri has disengaged from our process, we respect her rights as we would for any registrant.

Background

A very brief summary of the situation considered by the NMC panel:

On 6 August 2017, an 89 year old woman who was resident in a care home deteriorated rapidly. Mrs Nasiri left her in the care of a healthcare assistant and sought advice from 111. On her return Mrs Nasiri was told by the healthcare assistant that the woman was unresponsive. Mrs Nasiri informed the assistant that the resident was dead. Mrs Nasiri was referred to the NMC by the coroner following the inquest. The panel considered three charges and found one proven, that Mrs Nasiri on observing that the woman had ceased breathing failed to attempt cardio-pulmonary resuscitation. A 12 month suspension was imposed.

Issues raised

I recommend if you want to understand the thorough assessment of this case conducted by the panel, then please read the full decision.

Here, I want to respond to some of the issues individual commentators have made about the decision. I particularly want to address the conclusion reached in an article in the Nursing Standard implying that the panel decision undermines best practice guidance and risks inappropriate treatment being given. This is not the case.

Guidance

“Decisions relating to cardiopulmonary resuscitation: Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing” exists to assist health and care professionals in these difficult situations:

“Healthcare professionals are aware that decisions about whether or not CPR will be attempted raise very sensitive and potentially distressing issues for patients and those emotionally close to them.”

In any discussion about this case, we need to remember that at its heart is the death of an 89 year old woman.

Concerns have been raised that the panel decision contradicts this guidance and may lead health and care professionals to conduct CPR when it is not in the best interests of the individual. 

Like the panel’s judgment, the detailed guidance is best read in full, but there is a helpful summary of main messages at the start, some of which are particularly relevant.

Guidance key points: Do not attempt CPR

The guidance advises:

“Considering explicitly, and whenever possible making specific anticipatory decisions about, whether or not to attempt CPR is an important part of good-quality care for any person who is approaching the end of life and/or is at risk of cardiorespiratory arrest.”

The panel decision shows that four days prior to the incident the GP had stated that the resident was quite weak and that a DNACPR needed to be discussed with her. However, this had not taken place and the resident did not have a DNACPR in place at the time of the incident. Clearly, if this discussion had taken place and had been documented, Mrs Nasiri would have been able to act in accordance with the wishes of the resident. This situation reinforces the need for these difficult conversations to take place and is the responsibility of all providers of care where people may be approaching the end of their life.

Guidance key points: blanket policies

The guidance advises:

“Every decision about CPR must be made on the basis of a careful assessment of each individual’s situation. These decisions should never be dictated by ‘blanket’ policies.”

Person-centred care is a cornerstone of good care and the guidance reinforces this point. It is therefore concerning to note the response Mrs Nasiri gave in her conversation with the 111 Doctor in response to their question as to whether resuscitation was attempted:

“No, I mean, just no, we haven’t got resuscitation here. We’re not, we are not, this is a nursing home, we are not doing it.”

Guidance key points: considered judgment

The guidance advises:

“Where no explicit decision about CPR has been considered and recorded in advance there should be an initial presumption in favour of CPR. However, in some circumstances where there is no recorded explicit decision…a carefully considered decision not to start inappropriate CPR should be supported.”

Section 8 expands upon this in more detail. 

In this case, the care home’s policy certainly focused on an initial presumption in favour of CPR:

“in incidents of sudden or unexpected collapse where a person has clearly not made any living will or indication of their views on resuscitation, best efforts to resuscitate should be undertaken in accordance with the competence and qualification of available staff to offer emergency treatment or first aid.”

The NMC recognised this but also explored whether Mrs Nasiri’s decision not to perform CPR was a carefully considered clinical decision by reviewing the evidence available to them but concluded:

“Apart from Mrs Nasiri’s assertions, the panel found no evidence before it to suggest that the decision not to attempt CPR was a carefully considered clinical decision.”

Fitness to Practise process

A key element of this case was that Mrs Nasiri was not present or represented at the hearing and in previous months had disengaged from the process. The panel very carefully considered whether they should proceed and this is documented in the decision. 

Once the panel had reached its decision that two charges were not proven and one was, they had to consider whether the facts amounted to misconduct and, if so, whether Mrs Nasiri’s fitness to practise is currently impaired. There has been criticism of the decision made and the subsequent sanction. However, the panel heard from the case presenter that Mrs Nasiri’s:

“…misconduct was easily remediable. She submitted that the misconduct occurred in the course of clinical practice and it is possible to carry out targeted specific training, reflection and supervision to demonstrate that the clinical failings have been addressed.”

The panel took into consideration the seriousness of conduct and potential consequences if the actions are repeated; the lack of insight into failings; and the lack of remediation as demonstrated by the registrant in reaching a decision to suspend Mrs Nasiri for 12 months. The panel also sets out what would assist Mrs Nasiri when the suspension order is reviewed.

I am struck by the full consideration of the panel that

“the misconduct was not fundamentally incompatible with remaining on the register”; “the public interest is also satisfied by trying to assist a nurse, who otherwise has had an exemplary career, to return to practise”; and “concluded that it [a striking-off order] would be disproportionate.”

Lessons to learn

So, what lessons would I suggest can be learned from this situation?

• All registered nursing and midwifery professionals must uphold the standards set out in the Code. These include always practising in line with the best available evidence and keeping their knowledge and skills up to date.

• If, as a health and care professional, you are faced with making a decision about CPR when an explicit DNACPR decision is not available, you should be supported if you make a careful, considered decision not to start inappropriate CPR. You will always need to demonstrate that this is what you did.

• On those rare occasions that registrants are referred into the Fitness to Practise process, please engage with the process. I know that it is hard but we want to ensure nurses, midwives and nursing associates are treated fairly and have every opportunity to present their case.

• And, more broadly, this case highlights the responsibilities of those in charge of running health and care services to ensure difficult conversations about end of life care take place at the appropriate time, and are clearly understood. There’s lots of good guidance available to support organisations and professionals to do this well and it needs to be a priority for us all.

Other recent news…