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Decision Report 201709322

  • Case ref:
  • Date:
    November 2019
  • Body:
    Tayside NHS Board
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    nurses / nursing care


Mr C complained about the clinical and nursing care and treatment provided to his late wife (Mrs A) during her admission to Ninewells Hospital. Mrs A was admitted with a history of leg swelling and a failing liver.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and from a nurse. In relation to the clinical care and treatment given to Mrs A, we found that the majority of the clinical management of Mrs A had been reasonable. However, we found that Mrs A's infection could have been handled better and that antibiotic therapy should have been started earlier. Given the failings identified, we upheld this aspect of the complaint.

In relation to the nursing care and treatment given to Mrs A, we found that the care delivered, documented and communicated was lacking at times. Also the specialist knowledge of nurses managing a patient with decompensated liver disease was lacking and the interventions needed to ensure a clear treatment plan was in place. We upheld this aspect of Mr C's complaint. However, we noted that the board has accepted and apologised for the failings in communication.

Mr C also complained that the board had failed to record an incident on the ward, in a reasonable way. The board accepted that on this occasion the actions of the nursing team fell below the standard they aimed to provide and apologised to Mr C. Therefore, we upheld this aspect of the complaint.


What we asked the organisation to do in this case:

  • Apologise to Mr C for the failings this investigation has identified The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

What we said should change to put things right in future:

  • Staff need to be aware of the policy around escalation of patients and the board needs an assurance mechanism in place to monitor if this is being followed.
  • All staff in the ward should have access to education specific to the speciality and patient condition - including care planning, nutrition and managing encephalopathy.
  • Gastroenterology staff should be aware of the indications of antibiotics in liver failure and the ‘liver bundle’ guidance in caring for patients with end stage liver disease.

Updated: November 20, 2019