NHS FIFE has been told to apologise to a Victoria Hospital patient who accidentally overdosed after being left to administer his own morphine following surgery.
The patient, Mr C, had been given the drug for post-operative pain, which was administered through a PCA (patient-controlled analgesia) device, a special syringe he operated.
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 Mr C 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. A pain nurse then stopped Mr C’s PCA, and prescribed alternative morphine-based pain relief.
Three hours after the PCA was stopped, Mr C started to show clear signs of an overdose. A doctor was called and he was given medication to reverse the overdose. 
Mr C’s wife complained on behalf of her husband, and in investigations, the ombudsman took advice from nursing, anaesthetic and general medical advisers.
They were satisfied that nursing staff had appropriately monitored Mr C’s condition, but noted that Mr C had shown signs of mild opiate toxicity before his overdose, and that 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 opiate toxicity which Mr C displayed in the hours after his surgery were short-lived, and his observations remained reasonable. 
The ombudsman decided that if Mr C could have eliminated the risk of an overdose if he had been reviewed by an anaesthetist to identify whether alternative medication was more appropriate.
NHS Fife was told to apologise to Mr and Mrs C for the failings and distress caused. 
The health board was also told to identify changesalterations to current procedures, to helpassist staff in identifying when they should seek an anaesthetic review.
Helen Paterson, NHS Fife director of nursing, 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 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.”