Patient died after being sent home in taxi
A health board has been criticised over the care of a woman who was sent home alone in a taxi from hospital in the middle of the night and who later died.
Staff at Monklands in Airdrie also missed abnormal blood test results for the 78-year-old patient and failed to offer her pain relief.
The Scottish Public Services Ombudsman (SPSO) said she was shocked by NHS Lanarkshire's actions in the case.
She has ordered the health board to apologise to the woman's family.
In her report, Rosemary Agnew described how the woman suffered from multiple health problems and had been brought into the emergency department at Monklands at 22:00 on 2 May 2016 by ambulance after complaining of abdominal pain and vomiting.
However, she was discharged a few hours later without her family being informed and without pain relief after doctors diagnosed gastroenteritis.
The woman's husband described how he found her distressed and in pain at their front door after she was sent home by taxi in her night clothes in the early hours of the morning.
The woman died on 5 May from ischaemic and valvular heart disease.
The ombudsman said clinical assessments of the patient and record-keeping by two different doctors who saw her fell below a reasonable standard.
Mrs Agnew said: "Had a more senior doctor overseen Mrs C's care and due attention been given to this test result, Mrs C may have been admitted to hospital for a period of in-patient care which may have avoided her death."
Her report added: "Although we cannot definitively say that Mrs C's death was avoidable due to the post mortem having shown severe triple vessel coronary artery atheroma and valvular heart disease, there was strong evidence that it may have been."
The ombudsman said she had "significant concerns" about the care offered to the patient and the health board's failure to recognise the issues raised by the case.
She said: "I am critical, even shocked, that this situation occurred at all.
"I am particularly critical that the board's own complaints investigation failed to identify any concerns about the circumstances involving an elderly and frail patient with multiple health problems being discharged home by taxi in the early hours of the morning."
She has made six recommendations to improve patient care and discharge practices at the health authority and ordered the board to apologise to Mrs C's family.
In response to the findings, Dr Jane Burns, NHS Lanarkshire acute divisional medical director, said: "We regret any instance where we fail to provide the highest standards of care for our patients and we will contact the complainant directly to offer our sincere apologies for the failings identified in the report.
"We have fully accepted the recommendations within the ombudsman's report and will develop an action plan to address them.
"The lessons learned will be shared to help avoid similar occurrences in future."