A dermatologist’s verbal instructions for a bleach bath to treat an elderly women with impetigo were misinterpreted by nursing home staff leading to the death of the patient from severe burns, an inquest has concluded.

The NSW coroner found the actions of Dr Lance Bear in 2014 amounted to a significant failing because the lack of written instructions meant the patient was mistakenly treated with a 50/50 dilution of household bleach by nurses at a residential aged care facility.

Dr Bear told the inquest he had recommended the woman be treated with a bleach bath comprising half a cup of bleach to half a bath tub of water. But he did not leave any written notes at the nursing home and the nurses believed he had advised the woman should be treated with a dilution of half bleach and half water.

The 87-year old woman who had dementia and limited English, died from severe burns after she was treated for five days with the 50/50 bleach water mixture applied by nurses using towels in the shower.

Dr Bear told the inquest he had not intended his treatment recommendations to be started immediately, but to be passed on to the woman’s GP to develop a special treatment plan for her, since the nursing home did not have a bath. He had written to the woman’s GP several days after his visit, but the letter only arrived after she had been treated and admitted to the burns unit.

The coroner said the dermatologist should have made more explicit treatment recommendations both verbally and in writing in a timely way to nursing home staff and also to the GP.

“I find that it was a significant failing of Dr Bear that he did not clearly and unambiguously record in the nursing home records that the bleach treatment was not to be commenced until further clarification had been provided,” she said.

“I also consider that Dr Bear should have told this to the nurses and [GP] Dr Savoulis verbally and that he should have made this clear in his letter to Dr Savoulis. Had these things been done, what occurred next could have been avoided.

“Additionally, I consider that the onus was on Dr Bear, as the specialist dermatologist, to provide subsequent clarification in writing as to the correct dilution of bleach and as to an appropriate method of administering the treatment in the shower.

“Having discovered that the nursing home did not have a bath and that his preferred treatment of bleach baths could not be administered to Mrs Pahiva, it was Dr Bear’s responsibility to make a clear recommendation as to precisely what ought to occur by way of treatment in the alternative.”

Expert witness Dr Deedee Murrell, a consultant dermatologist, told the inquest that bleach baths were an appropriate treatment for bullous impetigo with MRSA, but the staff responsible for administering the bleach bath should have been given an information sheet or something in writing rather than just verbal instructions.

The inquest also concluded that the registered nurses in the facility should have sought further clarification and guidance from doctors about the treatment, especially since they were unsure about using bleach.

The coroner made recommendations for nursing home staff to have assertiveness training to encourage them to speak up when they have doubts or concerns about a doctor’s advice.

She also recommended 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.”