NHS Fife has been told to apologise to a Victoria Hospital patient who accidentally overdosed when he was left to administer his own morphine after surgery.
The Scottish ombudsman said the board should apologise for the failings identified in the man’s care and for the distress caused.
His wife, identified only as Mrs C, complained on behalf of her husband, who had an operation at the Kirkcaldy hospital.
He was given a special syringe of morphine which he operated to give pain relief on demand.
Over the next 18 hours, he administered his own morphine, within limited doses.
Nursing staff contacted the hospital at night team when they became concerned about the amount of morphine he had received.
But he was not seen by a doctor until ward rounds the next morning.
Concern over his pain relief led to a referral to the pain team and a pain nurse stopped his patient-controlled device and prescribed alternative morphine-based pain relief.
Three hours after this device was stopped he started to show clear signs of an overdose.
A doctor was called in and Mr C was given medication to reverse the overdose.
In investigating, the ombudsman took advice from nursing, anaesthetic and general medical advisers.
They were satisfied nursing staff had monitored his condition appropriately, but as Mr C had shown signs of mild opiate toxicity before his overdose, a review by an anaesthetist should have been requested either at those times or when he was seen by the pain nurse.
The signs of overdoes were short lived and his observations remained reasonable.
The investigation found if he had been reviewed by an anaesthetist to identify if other medication was more appropriate that could have eliminated the risk of an overdose.
NHS Fife director of nursing Helen Paterson said: “NHS Fife expects that all patients requiring our care have a positive experience, and the vast majority do.
“We accept, however, that some elements of the care provided in this instance were not of the high standard that our patients should receive.
“We treat all complaints with the upmost importance and are keen to learn from such experiences in order to enhance the services we provide.
“The ombudsman’s findings in this case will be carefully considered and its recommendations implemented in full,” she said.