22. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone seriously wrong.
Pain management planning
23. Mrs O complains the Trust had an inadequate pain management plan in place over the bank holiday weekend, given the complexity of her mother’s needs. She says that the doctor that reviewed her mother on Sunday 12 April failed to replace the Butrans patch with any alternative pain relief. This left Mrs L without sufficient pain cover over the bank holiday weekend when no doctors were on site.
24. The clinical records show a GP consultation took place on 10 April 2020. Mrs L is reported as ‘struggling with pain’ although it is not clear whether this is an observation from the staff, an assessment from Mrs L, or both. It is not clear from the records whether Mrs L, who is noted to have dementia elsewhere in the clinical record, was able to communicate the severity and characteristics of the pain. Her past history relating to vascular disease is noted, and a brief examination finding of ‘dusky legs right greater than left’ is recorded. A plan of action is recorded. This was regular paracetamol (a painkiller which was previously been given on an as required basis) and start Butrans 5mcg/hour. Butrans is a form of morphine given as a patch which releases the drug at a steady rate. The GP also records that the effect should be monitored.
25. GMC Good Medical Practice Section 15 states:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: · adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient · promptly provide or arrange suitable advice, investigations or treatment where necessary · refer a patient to another practitioner when this serves the patient’s needs’
26. The GP ascertained her history, examined Mrs L, and provided a treatment plan with advice to monitor the response of treatment. This complies with the standards outlined by Good Medical Practice Section 15.
27. Our GP adviser confirmed that the prescription of Butrans 5mg/hour transdermal patch was in keeping with the advice from NICE regarding Critical limb ischaemia. NICE Clinical Knowledge Summary/ Peripheral arterial disease/Management/Critical limb ischaemia states paracetamol should be offered, and either weak or strong opioids, depending on the severity of the pain. The GP prescribed Butrans patch which is a strong opioid.
28. We consider that the GP assessed and managed Mrs L’s pain in line with relevant standards and guidance in the consultation on 10 April 2020.
29. The records show nursing staff monitored Mrs L for the effect of the Butrans patch as instructed. At 6pm on 11 April they removed the patch as she had been ‘agitated and her behaviours were exacerbated’.
30. At 9.15am on 12 April, nursing staff called the OOH GP. The nursing records note Mrs L had not slept, was distressed, and had involuntary movements.
31. The clinical notes for the GP attendance on 12 April show the GP reviewed Mrs L’s history. The records document there is minimal oral intake, and that the observations were stable. Under examination findings the GP documents that Mrs L was ‘not distressed’ and ‘denies pain’ and that the right leg was dusky. They also document a discussion with a family member, Mrs L’s son -in -law, regarding escalation to DGH (we assume that this is the district general hospital). The GP prescribed lorazepam and midazolam as and when needed.
32. The GP considered Mrs L’s history, examined the patient, spoke with the family and prescribed treatment. Again, we consider this assessment to be within the standards outlined by Good Medical Practice Section 15.
33. In terms of pain management, the GP assessed Mrs L and documented an assessment of pain, during which Mrs L denied being in pain. The GP would have been aware that the Butrans patch had been removed because the clinical entry on 12 April 2020 was directly above an entry made on 11 April 2020 at 6pm documenting that the Butrans patch had been removed.
34. Looking at the NICE guidance for the management of critical-limb-ischaemia, paracetamol was being prescribed, as per the guidance. Our GP adviser confirmed a nonsteroidal anti-inflammatory drug would not have been appropriate because of Mrs L’s other medications, and a strong opioid had been prescribed but caused an adverse reaction.
35. Our GP adviser confirmed there remained the possibility of prescribing a weak opioid analgesic if the GP felt that was required. Codeine, which is a weak opioid, appears on the drug chart on 8 April 2020, but there is a line through this. When this was crossed off is not clear, and the codeine does not appear to have been dispensed. It is not clear from the records whether codeine was still to be considered if Mrs L subsequently appeared to be in pain again or complained of pain herself.
36. The records show the GP assessed and managed Mrs L’s pain in line with relevant standards and guidance on 12 April, given that the GP found Mrs L not to be in pain or distress. In terms of a pain management plan, as Mrs L was under the care of a nursing team, it is reasonable to expect that if the nursing staff caring for Mrs L determined that either her pain or her distress was not being adequately addressed, they would seek further medical advice. This is supported by the fact that this was the second call out to the OOH GP over the weekend.
37. We understand how concerned Mrs O and her family were about Mrs L, and how distressing it was to see her so unwell. We consider the consultations on 10 and 12 April which show the Trust assessed and managed Mrs L’s pain in line with relevant standards and guidance and implemented an adequate pain management plan for the weekend. As we see no indication of a failing, we will not investigate this aspect further.
Nursing care
38. Mrs O and her daughter visited her mother for over three hours on the afternoon of Sunday 12 April. She says during this visit her mother was notably distressed, and it was clear to them she was in a lot of pain. She says the pain was actively preventing her mother from being able to rest.
39. Mrs O complains that nursing staff did not acknowledge her mother was in pain. She says when the family tried to demonstrate the pain her mother was in by videoing her discomfort, nursing staff refused to look at this. We understand how upsetting it would be to see your mother agitated and in pain. We also take on board Mrs O’s concern that her mother would not always acknowledge her pain to professionals, which is why they recorded her distress to show the nursing staff.
40. The medical records do not show a specific pain assessment tool being used but do indicate that Mrs L’s pain was being assessed. Intentional Rounding (IR) is a structured process whereby nurses in hospitals carry out regular checks with individual patients using a standardised protocol to address issues of positioning, pain, personal needs, and placement of items. The IR charts show she was reviewed at regular intervals between midnight and 12 noon on 12 April. She was noted to be experiencing some pain between 6.30am and 7.30am. Paracetamol was administered, as prescribed, at 8am. The IR chart shows no further pain indicated at 8.30am, 9.15am, 11am or 12 noon. The next entry on the IR chart is at 3pm and records that Mrs L did not appear to be in any pain.
41. At 10.45am, the notes record that Mrs L is moved to a side room to accommodate the family’s visit. The Trust’s nursing records note at 2pm the family’s view that Mrs L was in pain, and their request that the OOH GP be called for further pain relief to be prescribed. They also record that when Mrs L was asked about pain with staff, she claimed not to be in pain. The records note that whilst talking to the family Mrs L had been sleeping and settled.
42. The Trust’s investigation report states staff did not feel it necessary to view the video the family were trying to show them as they did not doubt what the family were saying. However, in their clinical assessment, Mrs L had since become more settled and, at the time in question, her pain levels did not require a further review by the OOH Team.
43. Under sections 13.1 and 13.2 of the NMC Code nurses must accurately identify, observe, and assess signs of normal or worsening physical and mental health in the person receiving care and make a timely referral to another practitioner when any action, care or treatment is required.
44. From the records we cannot determine that nursing staff failed to acknowledge Mrs L was in pain, for the period in question on 12 April. We have seen that regular IR was completed, which considered pain. This is in line with the NMC Code. When the family raised concerns of pain this has been documented in the records. On this basis we cannot say that the staff failed to acknowledge Mrs L’s pain.
45. Mrs O complains that nursing staff failed to escalate the situation to a doctor on the afternoon of 12 April. She says they failed to call the OOH service because they had already called the doctor out that morning.
46. As referred to above, at 9.15am on 12 April, a nursing entry notes that Mrs L had not slept, was distressed, and had lots of involuntary movements. Nursing staff appropriately contacted the OOH GP for advice in line with the NMC Code. The GP clinical assessment recorded that Mrs L was not in pain at that time and the IR charts up until 12 noon indicate Mrs L did not appear to be in pain.
47. There is a detailed nursing record at 2pm recording the discussion with the family. This states that staff at that time did not feel the need to call the OOH GP as Mrs L ‘is stable and actually more restful than she has been’. At 3pm the IR charts recorded Mrs L did not appear to be experiencing pain.
48. Given the gap in the IR charts between 12 noon and 3pm it would not be possible to establish what Mrs L’s pain experience was during these times. We have the account of Mrs O and the family that Mrs L was demonstrably in pain, and the nursing entry at 2pm indicating that whilst they were having the conversation, Mrs L was sleeping in bed and was more stable and restful than she had been.
49. It is evident that when concerned about Mrs L’s condition, nursing staff contacted the OOH GP service earlier that day. It is also apparent from the entry on 13 April, that when Mrs L was distressed and experiencing pain, nursing staff did escalate concerns to the OOH service. Based on their review of the records, our nursing adviser confirmed that there is nothing to indicate that nursing staff should have contacted the OOH GP again on 12 April.
50. Mrs O also complains that nursing staff failed to competently administer medication when required. Under section 17 of the Royal Pharmaceutical Society and Royal College of Nursing 2019 Professional Guidance on the administration of Medicines (RPS Guidance), nurses must make a clear and immediate record of all medicines administered.
51. The medication charts record nursing staff giving Mrs L the prescribed doses of paracetamol at 8am and 12 noon on 12 April. Mrs L is shown as declining the dose at 6pm. As she is recorded as being in some pain on the evening of 12 April, nursing staff administered a prescribed dose of 0.5mgs of lorazepam at 9.45pm. Mrs L is also recorded as having declined the paracetamol dose at 10pm. All the IR records for that night record there was no appearance of a pain.
52. On 13 April, the records show Mrs L appeared agitated at 1.20pm and 6.20pm. Nursing staff administered the prescribed lorazepam at both times. Midazolam was administered at 10.20pm. Later that evening it appears that the pain has worsened, as had Mrs L’s condition. The records do not indicate the severity of the pain or the response to treatments administered, other than the injection of midazolam had minimal effect. The nursing staff sought advice from the OOH GP who prescribed morphine sulphate, midazolam, and cylcizine. These were administered as prescribed, which from the documentation appears to have been effective.
53. Our GP adviser confirmed the records show that nursing staff dispensed medication to Mrs L in line with the GP care plans.
54. We recognise this was a very difficult time for the family and they obviously wanted the best possible support for Mrs L. We have seen that actions by nursing staff were in line with RPS Guidance. On this basis we will not be investigating further.
Attitude of nursing staff
55. Mrs O says there were notices on the ward saying their number one priority was to listen to patient and relative concerns. She feels staff did not do this on 12 April. When the family tried to demonstrate the pain her mother was in by videoing her discomfort, nursing staff refused to look at this. She says when they asked for a doctor to review her mother and make the decision about pain relief, staff told her daughter they ‘weren’t having patient relatives telling them what to do.’ She feels this was both unprofessional, and rude, and implied that staff felt they were exaggerating the need for increased pain management.
56. We understand how upsetting it would be to feel your concerns were not being listened to in what was a very difficult and emotional situation.
57. In the Trust’s investigation report, the nurse in question states they are sorry the family’s perception is that they acted unprofessionally, but they believe they did act professionally where ‘it was being insisted in a very emphatic manner’ that they view the video of Mrs L. The nurse goes on to state they did not feel it necessary to view the video as they did not doubt what the family were saying. However, in their clinical assessment Mrs L had since become more settled.
58. The nursing records for the afternoon of 12 April are detailed. These record the nurse ‘explaining’ to the family that the nurses on duty will make the ultimate decisions about what medication they give to Mrs L. The records state ‘we can’t go on family request but will listen to their opinions obviously.’
59. We do not doubt Mrs O’s account of the events. This was evidently an emotionally charged situation. The accounts of the nursing staff and Mrs O are not dissimilar in terms of what occurred and was said. However, it is clear the parties perceive those discussions and events very differently. As we were not present at the time, we cannot reach a decision as to precisely what occurred. This means we cannot establish whether staff were rude and unprofessional towards Mrs O and her daughter. We will therefore not take further action on this element of the complaint.