By Grant Smith

NURSING STAFF at Ninewells Hospital in Dundee have been cleared of failing to monitor a patient who collapsed after wandering out of his ward and later died.

A series of complaints about the man’s treatment was made by his daughter to the Scottish public services ombudsman. The results of the inquiry were released yesterday.

The man, known only as Mr A, had chronic obstructive pulmonary disease and was admitted to Ninewells in September, 2005. He was in a frail condition and medical records showed he had been showing signs of confusion in the hours leading up to his death.

On the morning of September 28, he got out of bed, left the ward and was found at the bottom of a flight of stairs outside the ward. He was returned to his bed but died later that day.

Mr A’s daughter alleged that inadequate monitoring by nurses had made it possible for her father to leave unnoticed, despite being connected to an oxygen mask and a catheter.

The ombudsman noted that the 30-bed acute ward was busy but had an appropriate level of staff at the time of the incident.

A nursing adviser, who provides expert advice to the ombudsman, said the level of monitoring was adequate and she could fully understand why staff could not anticipate that Mr A would be capable of unassisted activity.

The inquiry report goes on, “She explained that it is difficult to ensure patient safety at all times and that, no matter how frequently it is planned to observe a patient, there will be times when the patient is unobserved.”

Similarly, the ombudsman’s medical adviser said that “even a confused, frail and ill elderly person can summon up the strength against all the odds to climb out of bed.”

He explained that the combination of the effort of negotiating the stairs and the loss of oxygen almost certainly caused Mr A’s collapse.

However, Mr A’s action could not have been predicted and it would have been unrealistic for him to be given constant observation. As “tragic and concerning” as the incident was, no blame could be levelled at the nursing staff, the medical adviser said.

Six days before his death, family members had visited the patient and learned that his catheter had become dislodged in the early hours of the morning and the doctor on call was not able to reinsert it because he was dealing with another patient at the time.

An external sheath called a uridome was applied but the family found that Mr A’s pyjamas and socks were saturated with urine. His catheter was not replaced until that evening, although the exact time of this is not known.

The nursing adviser told the ombudsman it was difficult to believe that in a large acute hospital nobody was available to perform the procedure for 16 hours or more and this delay was too long.

The ombudsman has told NHS Tayside to apologise to the patient’s family, which it has agreed to do.

The family also complained that when they arrived to pay their last respects after Mr A’s death, one member of staff blamed his collapse in the stairwell for a bruise on his forehead while another said he had hit his head on the cot sides.

However, the ombudsman ruled that it had not been possible for clinical staff to determine conclusively what caused the bruise and that was probably why two different reasons had been given.

Mr A’s daughter also suggested that he had been given too many drugs, making him sleepy and confused, but the inquiry found that he had been medicated appropriately and the confusion was almost certainly due to the onset of heart failure.