A patient was sent home from hospital despite having suffered an overdose of morphine.
The man had been rushed to Perth Royal Infirmary (PRI) with abdominal pain and vomiting but was assessed by a nurse as fit to be discharged.
His family became concerned, however, when the man identified only as Mr A was “confused and disorientated” in a phone call.
Now their complaint to the Scottish Public Service Ombudsman (SPSO) regarding their relative’s treatment has been upheld.
NHS Tayside has been ordered to apologise for its failings and to review record-keeping and assessment practices with the nurse concerned.
In its written judgment, the SPSO said: “Mr A had suffered a morphine overdose and become unwell. An ambulance was called and the crew assessed Mr A.
“He was nauseous and vomiting, had abdominal (stomach) pains and was unable to keep down food or drink.
“He was taken to Perth Royal Infirmary, where he was triaged and sent to the out-of-hours service. He was assessed there by a primary care nurse and deemed fit to be discharged.
“His niece (Mrs C) complained on behalf of Mr A. She said that when Mr A had been discharged he had phoned her and was confused and disorientated.
“Mrs C complained that her uncle was not reasonably assessed at the hospital and should not have been discharged.”
The SPSO said its GP and nursing advisers had expressed concerns.
“The nursing adviser was concerned that Mr A’s recent morphine overdose history was not noted and that his abdomen was not examined in light of the pain reported to the ambulance crew,” said its report.
“The GP adviser was also concerned that Mr A was not assessed for dehydration due to his inability to keep down liquids.
“We recommended that the board share the outcome of this investigation with the practitioner concerned to reflect on assessment and record-keeping and apologise to Mr A for the failings identified.”