A north-east health board has apologised to a family after it failed to provide proper care and treatment to a patient.
The Scottish Public Services Ombudsman (SPSO) has upheld a complaint made to NHS Grampian involving a patient who was not given the treatment they needed.
A report notes that the patient, who was admitted to hospital due to progressive vomiting and nausea, had been examined by a staff member from the dietetics team.
It was recommended that the patient, known only as A, was prescribed thiamine, otherwise known as vitamin B1, for malnutrition.
But they did not receive the thiamine supplements. The patient had recently lost 10% of their body weight but was discharged several days later as their symptoms had improved.
However, several weeks later, they were readmitted with confusion and reduced mobility and diagnosed with Wernicke’s encephalopathy, a condition which affects the brain and is caused by a lack of thiamine.
A relative, referred to in the report as C, complained that NHS Grampian had failed to provide reasonable care and treatment to A by not providing a prescription of thiamine, and that it had been unreasonable in discharging the patient from hospital.
The SPSO report states: “We took independent advice from a consultant gastroenterologist. We noted that the board had previously acknowledged that there was a failure to give A thiamine when originally recommended by the dietetic team, and they had apologised for this.
“They had also implemented a ward round checklist to prevent similar failings recurring.
“However, based on the advice we received, we were concerned that the board had not fully considered or accepted the potential impact of this failure, as we considered that thiamine supplements may have at the very least lessened the severity of the Wernicke’s that subsequently developed. We upheld C’s complaint.”
The SPSO asked NHS Grampian to apologise to the relative for failing to provide their sibling with the supplement, and for failing to acknowledge the potential impact of this.
It also said that changes needed to be made which should include making staff aware of the potential impact of thiamine deficiency.
A spokesman for NHS Grampian said: “We accept the findings of the SPSO and its recommendation.
“This case, unfortunately, represents an occasion where we did not meet the high standards we aspire to.
“We have already apologised to C and A but would take this opportunity to do so again publicly.”