SPSO (Scottish Public Services Ombudsman) decision

Tayside NHS Board

Decided 1 December 2021 Reference 201908805 Outcome: Not Upheld Sector: Health Category: Clinical treatment / Diagnosis Body on this site: NHS Tayside

Themes assigned by this site (AI-generated): Clinical negligence harms learning

Full decision

Decision (the SPSO's words)

Summary

C complained on behalf of their parent (A) about the actions taken by the board. A took a number of medications and over the years C became concerned about A's capacity to administer their own medication safely. There was an accidental overdose when A took too much Warfarin (a blood thinning medication). C complained about the care and treatment that A received following the overdose and that the board failed to ensure A could safely administer their medication.

We took independent advice from a specialist district nurse. We found that, as A was not bleeding, it was suitable for them to be treated in the community. Appropriate monitoring was carried out and no untoward events occurred for A while they were managed in the community.

We noted that district nurses had a role to play in keeping A safe. However, it was not normally their role to administer regular medication and not their sole responsibility to ensure that A was supported in their home to carry out everyday tasks safely. We found that the district nurses had acted reasonably and appropriately, and responded promptly when problems had arisen. We also noted that the record-keeping was of a very high standard.

We did not uphold C's complaints.

Related reading

View Decision Report 201908805 as a PDF (24.33 KB) Updated: December 22, 2021

From: SPSO (Scottish Public Services Ombudsman), decision 201908805, 1 December 2021