Nurses extinguish an older woman in BLEACH 650 times as strong as what she needed, causing her to die from serious chemical burns
- Epenesa Pahiva, 87, home for five days in a care home
- Nurses noticed that she was upset and in pain with red areas all over her body
- Pahiva spent six weeks in a burn unit until she died in September 2014
- Pahiva was treated with a solution of one on one instead of half water half bleach
A series of assumptions and miscommunication led nurses to extinguish an older woman about 650 times too strongly in a bleaching solution, a coroner has discovered.
Epenesa Pahiva should have been treated with a solution from half a cup of bleach to half a bath of water – but instead the solution was made one on one.
The 87-year-old former teacher and great-grandmother bathed for five weeks in July 2014 with towels soaked in the scrubbing solution at non-profit Castellorizian Aged Care Services.
Epenesa Pahiva (photo left) should have been treated with a solution from half a cup of bleach to half a bath of water – but instead the solution was made one on one
A nurse then noticed that she was & # 39; sad, in pain and with large red areas over her body & # 39; and called triple zero.
Pahiva spent six weeks in a burns unit until September 2014, the month in which she died.
NSW Coroner Teresa O & # 39; Sullivan on Friday found the dermatologist who saw Mrs. Pahiva's bacterial skin infection on July 11, 2014 and had advised treating it with a highly diluted bleach solution, usually reserved for a bath.
But Dr. Lance Bear could not tell the doctor of the wheelchair-bound woman or the nurses at the house that he did not want the treatments to begin until he had worked out how to treat her precisely in the shower.
The coroner said he had not recorded his intentions.
& # 39; It was a significant failure of Dr. Bear, & # 39; said Mrs. O & # 39; Sullivan.
Mrs. Pahiva (photo) spent six weeks in a burns unit until September 2014, the month in which she died.
& # 39; I believe that Dr. Bear this orally to the nurses and (general practitioner Thomas) Savoulis should have told and that he should have made this clear in his letter to Dr. Savoulis.
& # 39; If these things were done, what happened afterwards could have been avoided. & # 39;
She said it was not unreasonable for the doctor and nurses to give the impression that the treatment would start immediately.
The nursing home had no bath, so Pahiva treated in a shower chair with towels in the one-on-one solution.
Mrs. O & # 39; Sullivan said she did not doubt the two registered nurses at Dr. Bear during his consultation & # 39; believe honestly & # 39; Dr. Dr told them to & # 39; half bleach and half water & # 39; to treat.
& # 39; However, I think they are mistaken, & # 39; she said.
None of the nurses involved sought clarification from Dr. Bear or Dr. Savoulis, despite the novelty of the treatment and the absence of notes by doctors.
Dr. Savoulis examined Ms. Pahiva on July 14, noted some redness and instructed & # 39; continue with the same treatment & # 39; – without checking the strength of the bleaching solution.
Nurses had noticed that Mrs. Pahiva (photo) was covered with red parts of the bleach and & # 39; sad & # 39; was in pain
Pahiva & dementia, born in nuie, had evolved so much in 2014 that it was mostly non-verbal or unable to communicate with healthcare providers in English.
An autopsy report presented to the study said Pahiva died due to the combined effects of chemical burns, heart disease and chronic obstructive pulmonary disease on a background of dementia.
The coroner advised the nursing home to find a way to remind clinicians of their obligations when prescribing new drugs, to provide nurses with assertiveness training and to have staff demonstrate their understanding of new skills.
The 87-year-old former teacher and great-grandmother bathed for five weeks in July 2014 with towels soaked in the application solution at a non-profit home Castellorizian Aged Care Services (photo)
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