Sep 30, 2019

‘Bleach bath’ inquiry recommends improved training


A coroner has recommended a nursing home review its training procedures after a resident died after being given a ‘bleach bath’.

Much-loved teacher

Epenesa Pahiva was born on 12 April 1927 on the Polynesian island of Niue. She was a schoolteacher all her working life, and after marrying Togia Pahiva, had eight children. The couple also looked after two other children. 

When she passed away, Ms Pahiva had 12 grandchildren and 13 great grandchildren.

Many members of Ms Pahiva’s family attend the coronial inquest, where it was clear she was much loved. Ms Pahiva was described in the coroner’s report as “a strong woman, who was kind, caring, generous and supportive”.

Ms Pahiva was diagnosed with dementia in 2007, and eventually went to live in a nursing home in Kensington, Sydney. By 2014, Ms Pahiva was wheelchair bound and had lost the ability to communicate with her carers in English.

When Ms Pahiva developed a rash, she was seen by a dermatologist who visited the nursing home, and it was from this point that a series of miscommunications led to Ms Haviva, on the dates 11, 12, 13 July 2014, being bathed with towels soaked in a scorching cocktail of half bleach half water.

Ms Pahiva was at times left alone wrapped in the bleach-soaked towels, and restrained in her shower chair by a safety belt to prevent her falling.

Dermatologist appeared rushed

When the dermatologist saw Ms Pahiva, he arrived around hours earlier than expected, and according to reports, appeared rushed.

The coroner, Teresa O’Sullivan, said she was satisfied that the dermatologist told the nurses on duty the appropriate treatment was bleach baths using half a cup of bleach to half a bathtub of water. 

She found the nurses were mistaken in their belief the dermatologist instructed them to use half bleach half water.

The nurses failed to confirm the treatment, despite the fact it was new to them and their strong concerns about it, with Ms Pahiva’s doctor, saying they were too busy and due to staff changes. 

The dermatologist did not write down his instructions.

“Distressed, in pain”

After the final bath was given to Ms Pahiva on 15 July 2014, a nurse “was shocked” by the resident’s condition. She called 000, and Ms Pahiva was taken to St Vincent’s Hospital by ambulance, where she was diagnosed with chemical burns.

The nurse noted in the resident’s medical records that, she “appeared to be distressed, in pain, with large red areas across her body. Serous ooze emanating.”

“Died of natural causes following treatment”

Ms O’Sullivan found that Ms Pahiva died of the combined effects of ischaemic heart disease and chronic obstructive pulmonary disease, against the background of chemical burns and dementia.

“Epenesa Pahiva died of natural causes, following treatment for a skin condition, which resulted in chemical burns, which were healing at the time of her death,” the coroner’s report states.

However, during the hearings, geriatrician Professor Joseph Ibrahim suggested that Ms Pahiva’s death was “premature” because it was “a major traumatic injury causing pain, significant physiological stress and requiring prolonged hospitalization does contribute to premature death”.

However, Ms O’Sullivan said she tended to “prefer” other expert evidence that Mrs Pahiva’s chemical burn wounds “had very little, if any, contribution to her death, and were not a direct cause of her death.” 

Coroner recommends improved training

Ms O’Sullivan, made recommended that the nursing home improve training of its care staff and improve documentation of treatments and medications. She suggested the nursing home put in place procedures to follow when a new treatment or medication is introduced for a resident.

Ms O’Sullican also suggested that all registered nurses and assistants in nursing receive assertiveness training to help them communicate with doctors and to raise matters internally.

In its written submission to the inquiry, the nursing home acknowledged Ms Pahiva’s care was “sub-standard and unquestionably deficient”. The facility’s manager apologized to Ms Pahiva’s family. Ms O’Sullivan offered her “sincere condolences to the family of Ms Pahiva, who lived a full life, surrounded by her large and loving family”.

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  1. Shocking outcome, not good enough answer to such abuse! Sounds discriminatory as well. Poor family to have to endure such ignorance in care & the systems response to it. Their grief must be twofold because of the lack of care to their love one.

  2. This story made me feel so sick and horrified at the torture that poor poor woman endured. The people working did their job as they were, or thought they were directed. So many rushed people without the time to ensure this was done correctly. The nursing home and the government are to blame for this. They won’t set proper staff to resident ratios, they run on a consistent understaffed level. Mind you I don’t see how the dermatologist was able to give an instruction for treatment without having to record that treatment plan in the file. How very unprofessional and against all industry guidelines. No one set out to intentionally hurt this woman yet through an inadequate system, under training and an industry more interested in turning profit this is the result.


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