| Scottish Public Services Ombudsman Professor Alice Brown said the man — referred to as Mr A — was admitted to Ninewells on April 20, 2006, and had his operation the following day.
He later suffered episodes of diarrhoea and vomiting and then a cardiac arrest and subsequently died on April 26.
The man’s sister — Ms C — complained first to NHS Tayside and then took her case to the Ombudsman, who found there had been a failure to properly monitor Mr A’s fluid levels on April 25 and to accurately control the flow of intravenous fluid as detailed on the prescription chart for April 26.
The Ombudsman said she welcomed steps taken by NHS Tayside to address the issue and recommended it apologise to Ms C.
“The board have informed me that a recent audit was completed to identify staff competency and to indicate if further education is required to assess and manage patients’ fluid balance,” she said.
“The Board stated there was no guidance or protocol to indicate when a patient had to be commenced on a fluid balance chart and that discussions were being held with the Practice Development Team about the issue.
“The Board have developed a quality improvement plan to allow appropriate action and have devised a guidance document which is being trialled to determine its efficiency.”
Ms C had also complained that her brother was administered laxatives inappropriately; that he developed gastroenteritis that was not treated appropriately; that the results of the post-mortem of his heart was at odds with his previous cardiac examination; that insensitive language was used to describe events leading to his death; that he was inappropriately taken for an X-ray shortly before his death and that nursing staff failed to monitor his condition appropriately.
However, none of these complaints was upheld. |
