Pain management
13. Before we decide if we should carry out a detailed investigation of 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 have not found any signs that something went wrong.
14. Mr I says he was in terrific pain in the evening and through the night after his total left knee replacement surgery in September 2021. He says nursing staff did not manage his pain.
15. Mr I says nursing staff gave him some pain medications, but they had little effect. He says he continued to report severe pain at eight or nine out of ten, but nursing staff did not manage this.
16. The Hospital said in the final response that Mr I had declared a sensitivity to nefopam and codeine, which are two of the main pain relief medications they use. But nursing staff gave Mr I paracetamol, ibuprofen, Oramorph, tramadol and morphine.
17. The Hospital said patients can experience muscle cramping after knee replacement surgery, which is very painful. The Hospital said the nurses could have possibly given Mr I more morphine or Oramorph, but they were concerned about his oxygen levels.
18. The records show nursing staff monitored Mr I’s pain using the visual analogue scale. Our adviser said the visual analogue scale is a measure of pain which allows a patient to communicate their pain levels, and healthcare professionals to better understand the severity of pain a patient is reporting. On this scale, five out of ten represents ‘moderate’ or ‘distressing pain’.
19. Mr I’s pain scores are documented in the records - nursing staff scored Mr I’s pain out of three, or out of ten. Our adviser said one scale would have been preferable for continuity, but it is clear which scale nursing staff used on each occasion.
20. The records show pain scores were zero (no pain) until 6.10pm on the day of the operation, when Mr I scored two out of three (moderate to severe pain). This is reflected in the nursing evaluation which says, ‘analgesia given, as starting to get some sensation back’.
21. The medication charts show nursing staff gave tramadol to Mr I at 7pm and 7.40pm, due to pain scores of eight out of ten. After this, staff gave Mr I Oramorph at 11.50pm, and morphine sulphate at 2.20am the next day. Nursing staff recorded Mr I’s pain as under control from 8pm on the day after the operation, and it stayed under control until the morning of discharge (two days after the operation), when Mr I scored two out of three. So, staff gave him tramadol at 6am and 12.15pm, and the nursing documentation states, ‘pain well controlled’.
22. Our adviser said clinicians would provide tramadol for moderate to severe pain, and morphine sulphate and Oramorph for severe pain.
23. The evidence shows nursing staff managed Mr I’s pain in line with the relevant NMC guidelines under ‘Procedures for the planning, provision and management of person-centred nursing care’:
‘3.5 Take appropriate action to reduce or minimise pain or discomfort.
10.1 Observe and assess the need for intervention for people, families, carers, identify, assess, and respond appropriately to uncontrolled symptoms and signs of distress including pain, nausea, thirst, constipation, agitation, anxiety and depression.’
24. Our adviser also referred us to Royal College of Physicians guidelines which state, ‘The symptom of pain should be recorded and responded to by the clinical team.’
25. We recognise Mr I has told us he was in a lot of pain while in hospital and this was incredibly distressing for him. We also accept he has told us he has suffered with additional health problems since these events, which he believes are directly linked.
26. The Hospital has apologised that Mr I felt his pain was not controlled and has advised that nursing staff will reflect on this. The Hospital has also said the pain medication could potentially have been increased and it will arrange for the nurses involved in Mr I’s care to undergo pain management refresher training.
27. We are reassured to see the Hospital has reflected on Mr I’s complaint and put in place measures to improve its service. We have found no signs that anything went wrong with this aspect of the complaint as the Hospital gave pain relief to Mr I in line with guidance.
28. In summary, the evidence shows the Hospital acted in line with the national standards and guidance when it observed and assessed Mr I’s pain levels and took action to minimise pain. So, we have decided not to further look into this part of his complaint.
29. For this next section of the statement, we have found the Hospital has already done enough to put right the impact of these events.
Complaint handling
30. Mr I says he raised his complaint to the Hospital in November 2021 and the Hospital misdirected him to escalate the complaint to the chief executive of the healthcare organisation that owned the Hospital at the time of the incident (Healthcare organisation A).
31. Mr I says the two organisations directed him backwards and forwards between them, and the Hospital only confirmed in March 2022 that the response it had given in December 2021 was its final response.
32. The complaint file shows Mr I did first raise his complaint to the Hospital in November 2021. The Hospital responded to his complaint in writing in December 2021 and advised Mr I he could contact the chief executive of Healthcare organisation A, or us if he remained dissatisfied.
33. Mr I contacted the chief executive of Healthcare organisation A in December 2021 and received a response in January 2022 to advise the Hospital was taken over by another organisation (Healthcare organisation B) in December 2021, so they would need to respond to the complaint.
34. There was further communication between Mr I and the Hospital, but the Hospital had not originally identified that his complaint was in relation to NHS care.
35. The Hospital acknowledged the frustration the delays would have caused and apologised to Mr I that staff did not explain the NHS complaints process to him. The Hospital also arranged to have a call with Mr I to discuss his concerns further to see if it could help to resolve the complaint.
36. In March 2022, the Hospital confirmed Mr I could contact us if he remained dissatisfied with its response and referred back to the final response letter provided in December 2021.
37. Our ‘Principles of Good Complaint Handling’ say that to put things right, organisations should give an apology, explanation and an acknowledgement of responsibility.
38. We recognise Mr I has told us about the frustration this caused him and his wife when trying to raise their complaint, and that this delayed them receiving their final response.
39. The Hospital has accepted some errors when handling Mr I’s complaint, which did prolong the process, but we believe the remedies the Hospital provided to be proportionate and in line with these Principles, so we will not investigate this area of complaint further.