AN ELDERLY woman died weeks after undergoing kidney surgery that should never have taken place, according to a watchdog’s investigation.

The Scottish Public Services Ombudsman condemned NHS Tayside for “serious failings” in the treatment of the woman, known only as Mrs A, after independent experts found that the decision to remove her right kidney at Ninewells Hospital in Dundee was unreasonable and had triggered “a cascade of medical complications”.

They said there was a “low risk” that Mrs A’s kidney cancer would harm her, but that she was “at exceptionally high risk from kidney surgery” due to her age and history of heart problems, including angina and a heart attack.

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The SPSO also criticised “a number of failings in Mrs A’s nursing care”, including the management of pressure sores, diabetes and nutrition, and found she had not been prescribed enough hours of pain relief once she was terminally ill.

She died in September 2017, the day after she had been sent home from hospital for end-of-life care.

Her daughter went on to raise a complaint with the SPSO after NHS Tayside’s own internal probe failed to identify any major problems with her mother’s care.

The family’s ordeal began in May 2017 when a routine scan for Mrs A’s heart condition picked up a small lesion on her right kidney, measuring less than two inches.

Doctors diagnosed a renal cell carcinoma, a type of kidney cancer, and she was referred for surgery at Ninewells Hospital in mid-August.

Within days of the operation, Mrs A began experiencing chest pain.

A CT scan showed a build up of blood in her pleural cavity and she underwent treatment with antibiotics and a chest drain, during which time she was transferred three times between coronary care and the respiratory unit.

The SPSO said there had also been an “unreasonable” three-day delay in carrying out tests to detect the problem.

When her condition failed to improve, Mrs A was transferred to Edinburgh for video-assisted thoracic surgery.

However, she subsequently developed ventricular fibrillation, a problem with the heart’s electrical signalling which can cause it to stop pumping blood.

Mrs A was transferred back to Ninewells where her condition deteriorated further and she was diagnosed with a pulmonary oedema, a build up of fluid in the lungs which causes breathing difficulties.

She did not want further medical treatments or investigations and in late September she was discharged from hospital to die at home.

The SPSO report states that previous studies have shown that elderly patients and those with pre-existing conditions who have small kidney lesions “have a low mortality rate from renal cell carcinoma and a high mortality rate from other causes”.

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A urologist consulted independently by the SPSO said the lesion “might not have caused her any harm” but that “Mrs A was at exceptionally high risk from kidney surgery because she was elderly and had significant heart problems”.

The risk of the cancer spreading was probably less than 2% but the SPSO found no evidence that the option of monitoring her condition with scans, instead of surgery, had been discussed with Mrs A.

The SPSO said: “It was inappropriate and unreasonable for the board not to have had these discussion with Mrs A. I am deeply concerned that the board have not recognised the importance of respecting a patient’s right to be fully informed.”

A spokeswoman for NHS Tayside said: “We are sincerely sorry that treatment and care in this case fell below the standard we would expect.

“We accept all the recommendations made in the report and an action plan is being developed to meet the recommendations within the agreed timescales.

“We will be contacting the family again to apologise and offer the opportunity for a meeting with the Clinical Lead for Urology.”