NHS Grampian has admitted “letting down” a man who died only two days after being discharged from Aberdeen Royal Infirmary.
The Scottish Public Services Ombudsman found there were signs his planned release from hospital should have been reviewed.
The man – referred to as Mr A in the SPSO report – had been admitted as an emergency patient because he was struggling to go to the toilet.
He had a catheter fitted and received further treatment under anaesthetic before being discharged.
Plans were made for the man’s condition to be reviewed as an out-patient by a urology specialist.
However, he died suddenly just two days later.
His sister, Mrs C, complained to the ombudsman over the care he had received at ARI.
The SPSO’s independent adviser reported there had been cause for renewed concern over his recovery.
On the day he was discharged he was still unable to go to the toilet normally and was producing lower levels of urine than normal.
The ombudsman ruled this should have prompted a urology review ahead of Mr A being let home, rather than having arrange it as an out-patient appointment at a later date.
The warning signs should also have been enough for staff to urgently review his continued inability to go to the toilet after he was discharged.
NHS Grampian was ordered to apologise to Mr A’s sister for failing to find out why his problems had continued before he was discharged.
The health board has also been told to ensure an assessment has been carried out into patients’ ability to use the toilet before they are let home.
A spokeswoman for NHS Grampian said: “We acknowledge we let down Mr A, and his family, and accept all of the ombudsman’s recommendations.
“We have written to Mrs C to apologise and would take this opportunity to do so again publicly.”