Ash Court Care Centre staff failed to give Vincent Bootman CPR

Published: 18 March 2010
by JOSIE HINTON

A CARE home in Kentish Town has carried out a review of its procedures after staff failed to attempt to resuscitate a resident who later died.

Retired soldier Vincent Bootman died in his room at Ash Court Care Centre, in Ascham Street, last September, after complaining to nurses of shortness of breath.

The centre’s GP told staff to call an ambulance, but when a nurse went into his room 20 minutes later, she found the 53-year-old had stopped breathing and had no pulse. 

No ambulance had been called.

At an inquest at St Pancras Coroner’s Court on Thursday, Mr Bootman’s sister Marie demanded to know why nurses did not start life-saving procedures. She also hit out at staff for leaving him alone for 20 minutes after being instructed by a doctor to call an ambulance.

Ms Bootman told the court: “He was left unattended in a dangerous situation. If you’re short of breath, 20 minutes is a very long time to be left alone.”

At the time of his death, Mr Bootman, a recovering heroin addict, was suffering from “complex problems” including kidney failure and chronic bone disease, but, crucially, he had not signed a Do Not Attempt Resuscitation (DNAR) order instructing staff not to perform CPR.

Nurses at the care home said Mr Bootman, who was described as “extremely poorly,” had verbally expressed a desire to be left to die.  They also said they feared chest compressions would cause “more harm than good” to his body.

Nurse Mary Rose Egbucien told the court: “He said he didn’t want to go to hospital. He said, ‘I’m finished with that’. I told him it’s the almighty God that will say when he should die. But he said, ‘If I die, I die’. It was better for the man to go with dignity.”

Ms Bootman criticised nurses for making a decision which “bore no relation” to what had been written down. 

And coroner Andrew Reid questioned staff over why the decision not to resuscitate Mr Bootman had not been “systematically or expressly recorded”. 

He said: “It seems that the decision not to perform CPR was made with reference to one of his conditions and it was made at a time when minutes before the GP wanted to send him to hospital.”

Joint guidelines issued by the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing state: “If patients decide that they do not wish to have CPR attempted, this should be carefully documented in the hospital, GP or health establishment’s records. In England and Wales, unless these records are signed by patients and the signature is witnessed, they are unlikely to meet legal criteria for a valid advance decision.” 

But Nancy Rasool, manager of Ash Court, said Mr Bootman was receiving end-of-life care. 

She told the court: “It was never assumed that we would do CPR. It wasn’t something that we mentioned.”

Ms Rasool said that changes have since been implemented at Ash Court following an internal investigation into his death. 

Recording an open verdict, Dr Reid said he could not be sure of the “precise circumstances” that caused Mr Bootman’s heart to stop, after a pos-mortem examination revealed an unexplained level of morphine in Mr Bootman’s blood.

Dr Reid added: “I’m not persua­ded that there was neglect in this case. Even if resuscitation had been commenced I’m satisfied he would still have died.”