Evening Telegraph (First Edition)
Health board told to tighten reviews
NHS Tayside has been told by a watchdog to tighten up its incoming patient reviews after a man who was missed on ward rounds later died.
The health board was issued with a formal recommendation by the Scottish Public Services Ombudsman (SPSO) after a complaint was raised by a sister of the man, known only as Mr A.
Mr A had been diagnosed with liver disease and admitted to the acute medical unit at Ninewells Hospital, during which time he was given medication for alcohol withdraw.
He was then diagnosed with acute kidney injury and treated with dialysis, but his condition worsened and he died after being transferred to intensive care.
Mr A’s sister, named in the SPSO’s report on the complaint as Ms C, claimed that Mr A had been missed during the doctor’s ward round the morning after his admission and that he was not referred to kidney specialists sooner as a result.
The SPSO’s report said: “Ms C felt the hospital was under-staffed over the weekend, and she felt this meant that Mr A’s condition was not taken seriously until it was too late.”
NHS Tayside conducted its own investigation and acknowledged some failings on its own part. The board admitted that Mr A had been missed on the ward rounds, that some documentation had not been fully completed, and that his family should have been told sooner of the seriousness of his condition. NHS Tayside also apologised to Mr A’s family and agreed a new process for ward rounds to ensure patients were not missed.
Ms C also had a meeting with health bosses, but found it “unhelpful” and got in touch with the SPSO.
The watchdog said it would uphold some parts of Ms C’s complaint.
It said: “After taking independent medical and nursing advice, we upheld Ms C’s complaints.
“While we found there were some omissions in nursing documentation, we found that the overall standard of nursing was reasonable. We recommend that the board demonstrate to us what steps they have taken to reassure themselves that the new system for ensuring consultant reviews of incoming patients on the acute medical unit is effective.”
NHS Tayside has been approached for comment but had not responded at the time of going to press.