The inquiry had heard during sittings in October and earlier this month that Mrs Troup was prescribed the anti-inflammatory and painkiller diclofenac, which is marketed among other names as Voltarol.

During the inquiry medical witnesses disagreed with the decision to give her that drug.

Sheriff Hughes said in his 38-page judgment that one medical expert had been “openly hostile” to Mrs Troup being given diclofenac in light of her medical history.

In his findings, the sheriff determined that death might have been avoided if diclofenac had not been prescribed, and it might also have been avoided if Mrs Troup had received close observation and examination during the hours immediately after it was administered.

The initial decision to prescribe diclofenac should have been regularly reviewed to take account of the results of the observation and examination, the sheriff stated, because of the risk of its use with frail elderly patients who shared Mrs Troup’s symptoms.

Sheriff Hughes said there were defects in the system of working which contributed to Mrs Troup‘s death, including a breakdown in communication among hospital staff.

Entries were made into records referred to as a Junior House Officers’ Book, but junior house officers who were caring for Mrs Troup were not aware of the book.

As a result, they and more senior doctors were unaware of concerns that had been raised about the administration of dicolfenac to Mrs Troup.

Another defect was that the hospital case management notes were kept separate from Mrs Troup’s medical records and a failure on October 21, 2002, by the doctor who prescribed diclofenac to consult her full medical records, which would have disclosed her previous history of renal impairment, hiatus hernia and reflux oesophagitis.

There was also a failure by junior house officers to consult senior colleagues regarding Mrs Troup’s medical complications following the initial administration of diclofenac.

Sheriff Hughes recommended that diclofenac and other non-steroidal anti-inflammatory drugs should be used with caution in elderly patients and those with a history of cardiac disease, renal impairment and previous gastrointestinal complications.

He recommended that in the event of diclofenac being administered to such patients there should be regular monitoring of the patient by senior members of staff in consultation with the consultant in charge.

If there was evidence of complications normally associated with the drug, it should be withdrawn immediately and an alternative medication should be used.

The sheriff also recommended that nurses and doctors of all rank should be fully aware of the existence of all patients’ records, and if a house officers’ book is to be employed then it should be noted accordingly, acted upon and signed by the relevant doctor who has acted on its information.

The book should be monitored by a senior doctor, and if a drug such as dicolfenac is to be used on a patient who shows symptoms of cautions and contra-indications to the drug, the prescribing doctor should keep a record of why he considers it appropriate to administer the drug.

The sheriff also said consideration should also be given to amending the Acute Pain Analgesia ladder to carry appropriate warnings about the use of diclofenac to elderly, frail patients who have symptoms of heart disease, renal impairment or a history of gastrointestinal problems.

He also called for an Acute Pain Management team to be available at Ninewells round the clock.

n The family of Daisy Troup welcomed the sheriff’s findings — and said they were now due an apology from the health board, writes Steven Bell.

Angry relatives are also not ruling out the possibility of a civil action against the authority after it emerged the pensioner’s death might have been avoided.

Mrs Troup’s daughter Sheila Krawczyk said, “We are delighted at what the sheriff has found. He has agreed that the death could have been avoided.

“We really appreciate the recommendations he has made and now hope that Tayside Health Board take these on board quickly and implement them.”

Mrs Krawczyk, who gave evidence at the FAI, said the family’s hope from the hearing had been to find out what happened and prevent further deaths.

They are calling for improve-ments to be made in the prescription of the drug diclofenac, in the monitoring of patients receiving it and in the training of young doctors.

“I would like to find out how many people are dying as a result of the mis-prescription of this drug,” continued Mrs Krawczyk.

She said it had also come to light during the evidence that there was “something lacking” in the training of five young doctors involved in the case.

The family said the findings justified their fight for an FAI to be held, a fight which included the intervention of their MP Andrew Welsh.

“I am angry at the health board, because after the death no one contacted us,” continued Mrs Krawczyk. “I know that legally they perhaps couldn’t because there was an investigation, but I think now they are due us an apology.”

Asked whether they had considered a civil action, Mrs Krawczyk said, “We haven’t up to now. We will obviously have to take legal advice.

“The main thing for us was first of all to find out what happened, and second to make sure it doesn’t happen to anybody else.”

NHS Tayside was asked to comment on the findings today, but hadn’t done so at the time of going to press.