Colleagues at the HSIB have issued a new report with several recommendations for improvement. HSIB investigated the care of a Patient in a hospital who was found unresponsive in bed. The team confirmed the Patient’s identity and noted that a decision had been made that he was not recommended to receive CPR if his heart stopped. CPR was not started. Around 10 minutes later a nurse who had previously been caring for the Patient returned from their break and recognised that the Patient had been misidentified as the patient in the next bed. The Patient whose heart had stopped was recommended to receive CPR. CPR was immediately started, but despite this, the Patient died.