Overview
Ms C complained about the care and treatment provided to her mother, Mrs A, in Ninewells Hospital (the hospital). Mrs A was admitted to the hospital to have a dialysis tube inserted but following the procedure a complication arose and Mrs A died.
Specific complaints and conclusions
The complaints which have been investigated are:
- (a) that the incorrect procedure was used (not upheld); and
- (b) failure to diagnose a complication (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Ms C for the distress caused to her and the rest of Mrs A's family by failure to diagnose the complication; and
- (ii) ensure that staff on wards which receive patients who have undergone tunnelled line insertion are aware of the possibility of this known complication and can recognise the symptoms of perforation of a major blood vessel.
The Board have accepted the recommendations and have acted on them.