Inquest into the death of Epenesa PAHIVA

Contributing factors

• failure by specialist dermatologist to document treatment plan clearly
• failure to write instructions in nursing home medical records
• nursing staff failure to obtain written treatment orders before commencing treatment
• absence of documented clarification from treating doctor regarding application method when bathtub unavailable
• misunderstanding by nursing staff of bleach concentration (heard 'half and half' instead of 'half cup to half tub')
• failure to seek family consent for novel treatment
• failure to contact doctor or referring GP for clarification despite concerns
• inadequate supervision and documentation of bleach treatment administration
• chemical burns from concentrated bleach solution (50% bleach to 50% water) inadvertently applied
• delay in recognition of chemical burns and transfer to hospital
• failure of general practitioner to arrange hospital transfer when chemical burns suspected
• patient left unsupervised during treatment while restrained
• lack of written wound care assessment after treatment commenced

Coroner's recommendations

1. That consideration be given to how clinical staff training can be delivered effectively, including methods of evaluating participants' competency in the knowledge and skills being taught
2. That consideration be given to identifying an effective method of reminding clinicians of their obligations when a resident is prescribed a new medication (such as, for example, placing a checklist on the resident's file or placing a sign somewhere prominent) including any need to seek family consent
3. That consideration be given to the current medication management policy as to whether it appropriately provides (i) for all medications to be written by the doctor on the resident's medication chart and (ii) for written instructions to be provided by the doctor when necessary, including for novel treatments, and (iii) to ensure that treatment is not commenced without that documentation being provided
4. That consideration be given to providing assertiveness training for Registered Nurses and Assistants in Nursing, particularly in relation to dealing with medical professionals, and raising issues of concern at an internal level