Dialysis patient found 'unresponsive' after medication mix-up in the Scottish Highlands

An NHS board has been ordered to apologise after a dialysis patient was found unresponsive after receiving two doses of their medication.

The Scottish Public Services Ombudsman (SPSO) instructed NHS Highland to apologise to a patient and their spouse, referred to as A and C to protect their anonymity.

C complained on behalf of their spouse (A) who was admitted to hospital with pain, spasms and weakness in their right leg which were later diagnosed as being an infection in the muscles running from their lower spine to their thigh.

The patient was already on dialysis, wheelchair bound and had a weakened right side from a previous stroke which C usually administered medication for.

During A’s first week in hospital, a mix-up saw both C and a nurse administer A’s evening medication.

One evening C administered the usual medication and left for a few hours only to return to find their spouse unresponsive.

It was later found that a nurse had also administered the evening medication despite C having previously been given the medication by ward staff to support A during their stay.

C complained that this overdose of medication had occurred and that record keeping and incident management had been “unreasonable”.

The SPSO investigated the claims with advice from a nursing adviser and upheld the complaint.

The watchdog found that the incident should not have happened and indicated a lack of “clarity, process, recording and communication within the ward”.

They found that record keeping before and after the incident to be lacking due to there being no “clear record” of a person centred care plan to state that the medication was being held and administered by C.

The SPSO also found that there was a 24 hour gap in nursing records over the period of the incident and that no extra observations or conversations with a doctor had been recorded following the incident.

The watchdog said the management of the incident was “unreasonable” and ordered the board to apologise for poor record keeping as well as the extra dose of medication.

They also ordered the board to provide evidence that they have implemented recommendations by a set deadline.