Inquest into the death of Epenesa PAHIVA

87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary disease, on a background of chemical burns and dementia

Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (half cup bleach to half bathtub water) was appropriate for her MRSA infection, but critical failures in communication and documentation led to improper administration. Dr B. failed to clearly document that treatment should not commence until further clarification was provided. Nursing staff, without written instructions and despite concerns about bleach's caustic nature, administered the treatment using a 50:50 bleach-to-water concentration starting 11 July 2014. The nurses did not seek written clarification, contact the referring doctor, or obtain family consent. Dr S., reviewing the patient on 15 July 2014, suspected chemical burns but did not arrange hospital transfer immediately or document his concerns. The patient's pre-existing cardiovascular disease was the primary cause of death; the healing burns contributed minimally. Multiple system failures in documentation, communication, supervision, and clinical decision-making were identified as preventable with proper protocols.