The Courier & Advertiser (Angus and Dundee)
Health chiefs told to apologise for patient’s death after ‘high-risk’ surgery.
NHS: Watchdog says operation was high risk and there were failures in late patient’s care after leaving hospital
Health bosses in Tayside have been ordered to apologise to the family of a woman who died following “exceptionally high risk” cancer surgery and a litany of failures in her care.
The patient, named only as Mrs A, developed excess fluid around her lungs and an infection following surgery to treat renal cell carcinoma, a type of kidney cancer, in August 2017.
The Scottish Public Services Ombudsman (SPSO) took independent advice from a consultant urologist and ruled the decision to refer Mrs A for the procedure was “unreasonable”.
It found there was a low risk the renal cell carcinoma would harm Mrs A but she was at exceptionally high risk from kidney surgery.
Investigators recorded failings in the consent procedure as risks and nonsurgical options had not been properly discussed.
Mrs A’s condition continued to worsen following the operation and she died the following month, one day after being discharged home for end of life care.
The SPSO found there was an “unreasonable delay” in recognising
“We will be contacting the family again to apologise and offer the opportunity for a meeting with the clinical lead for urology. NHS TAYSIDE
she had developed a collection of blood in the lung cavity, but this was subsequently treated appropriately.
A report by the watchdog outlined how NHS Tayside also failed to give Mrs A reasonable nursing care, or provide proper pain relief when she was sent home.
It says: “We found a number of failings in Mrs A’s nursing care in relation to the prevention of pressure ulcers (an injury to the skin and underlying tissue, usually caused by prolonged pressure), diabetes management and nutritional care.
“We found Mrs A was not prescribed enough hours of pain relief medication and she should have been given a syringe driver (a machine that delivers continuous pain relief medication), as otherwise a carer would have had to give her hourly injections.”
NHS Tayside has been told to make eight improvements, including giving “full consideration” in similar circumstances to non-surgical treatment options for patients with renal cell carcinoma.
The health board has now apologised to Mrs A’s family but the SPSO said it expects evidence appropriate action has been taken.
A spokeswoman for NHS Tayside said it was “sincerely sorry that treatment and care in this case fell below the standard we would expect”.
She added: “We accept all the recommendations made in the report and an action plan is being developed to meet the recommendations within the agreed timescales.
“We will be contacting the family again to apologise and offer the opportunity for a meeting with the clinical lead for urology.”