Pain relief 15. Ms J says that from 12 February her father was calling her to tell her he was in pain, so she had to call the ward to tell them. She believes the Trust did not properly control her father’s pain. We understand this was upsetting for Ms J especially as she was not able to visit her father due to COVID-19 visiting restrictions at the time.
16. The Trust said it gave Mr P paracetamol and on one occasion codeine to control his pain. The Trust did not give dates of when the paracetamol and codeine was given. But the Trust said Mr P only complained of pain on 18 February.
17. The NICE Analgesia CKS guidance, based on the WHO pain ladder, suggests that pain relief should be increased in steps, starting with simple analgesics like paracetamol and then trying or adding either anti-inflammatory drugs (which our adviser says would not have been appropriate because of Mr P’s internal bleeding) or a week opioid like codeine. It also says the cause of pain should be addressed wherever possible.
18. Section 16 of Good Medical Practice says doctors should take all possible steps to relieve pain and distress whether or not a cure may be possible.
19. Mr P’s medical records show he was prescribed codeine, but he was only given it once on 11 February. The BNF says codeine can be given as a short-term treatment of acute moderate pain.
20. On 12 February, records show Mr P had indigestion pain. The prescription charts show the Trust started Mr P on peptic and gave this four times a day for indigestion. Peptic is an alginic acid and the BNF lists acid reflux as a reason to prescribe this drug. Our adviser confirms that indigestion pain is usually due to acid reflux.
21. On 13 February, nurses scored Mr P’s pain as zero. This may have been because he had been prescribed and was continuing to take peptic.
22. On 14 February, the records say Mr P was not in pain but do mention indigestion discomfort. Mr P was continuing to take peptic four times a day.
23. The next time that nurses recorded pain scores was on 15 February. His pain score was again recorded as zero. But records show Mr P had mild pain that evening and he complained of back pain. Staff gave him paracetamol on 15 February at 6.39pm.
24. On 16 February, staff recorded Mr P as having mild pain and gave him paracetamol at 1.06pm.
25. On 17 February, staff again recorded Mr P as having mild pain. Mr P was not given any paracetamol, but he was given pantoprazole which, like peptic, is used to reduce acid in the stomach. Mr P also said he felt constipated and was prescribed Laxido to be taken twice a day. Laxido is a laxative that helps to soften and ease the bowels.
26. On 18 February, no pain was recorded but the records show that Mr P was given paracetamol at 11.45am. The records show that Mr P had a medical review at 11.29am that morning, so it is likely that he told the doctors he had some pain or discomfort and they prescribed the pain relief. We can see that Mr P also had two doses of pantoprazole on 18 February.
27. Ms J remembers what happened on 18 February. She told us her mother spoke with her father in the evening and he told her he was in ‘lots of pain and feeling really ill’. She says her mother spoke with him again and he again told her he was in pain and had only been given two paracetamol. She is sure at this point that her mother called the ward to tell staff the pain relief he had been given was not enough. We cannot see that Mr P was given any more pain relief, but we can see that staff were completing tests to explore the cause of his pain.
28. Ms J told us her father was calling her throughout his admission and saying he was in pain. Given that she was unable to visit her father due to visiting restrictions, hearing this from her father will have caused her distress, upset and worry at an already difficult time.
29. Taking into account our clinical advice, we think that when Mr P told staff he was in pain or discomfort he was given pain relief in line with the NICE Analgesia CKS. The medical notes show there were medical reviews from the medical team and pain was not recorded as a major issue during these consultations.
30. The prescription of peptic on 13 February and the pantoprazole and Laxido on 17 February is in line with the NICE Analgesia CKS in trying to address the cause of the pain. Mr P was complaining of indigestion and constipation pain and this medication was to relieve his symptoms.
31. Mr P being given paracetamol and codeine infrequently would not have suggested to the medical team that more or stronger pain relief was needed. There may be explanations for this, like intermittent or fluctuating pain, or partial responses to the medications. There is not enough evidence for us to be able to take a view on this.
32. It is clear that Ms J’s memory of her father reporting pain is different from the Trust’s records, which do not suggest failings in the control of his pain. We do not doubt what Ms J says. Overall, the available evidence does not show there were failings in the management of Mr P’s pain.
End of life visiting
33. Ms J complains staff did not tell her about her father’s deterioration and she and her mother did not have the opportunity to see him before he sadly died. In the Trust’s complaint response it said nursing staff and doctors were reviewing Mr P closely over his final hours, but as he deteriorated rapidly there was no opportunity to contact the family until after he died. It also said the nursing team were not aware of the seriousness of Mr P’s condition. It assured Ms J that had it known how poorly Mr P was, it would have called and asked for her to come to the hospital, despite the no visiting policy in place at the time.
34. Throughout the COVID-19 pandemic, the Trust followed a policy based on guidance from the government and NHS England. The Trust’s policy says visitors could not routinely visit patients apart from in exceptional circumstances. Exceptional circumstances include end of life care. This guidance was in place during Mr P’s admission.
35. Records show that shortly before his death, Mr P was stable until the evening when his blood pressure dropped. In response to this, a doctor reviewed Mr P and staff treated him with fluids. Shortly after, he started vomiting. Staff inserted an NG tube to drain liquid from his stomach to improve his symptoms. Mr P went into cardiac arrest. We accept that Mr P’s deterioration was sudden and did not allow staff to contact Ms J as they were focused on trying to restart Mr P’s heart.
36. Throughout his admission, Mr P had active treatment to reduce his symptoms. We have not seen any evidence to show he was getting end of life care or that staff should have anticipated he would sadly die when he did. This means that in line with the visiting restrictions in place at the time, the Trust could not have called Ms J.
37. We understand how difficult it was for Ms J and her mother to not be able to visit Mr P because of pandemic visiting restrictions. Mr P’s deterioration was sudden and, sadly, there was not an earlier opportunity to tell his family as staff focused on emergency treatment for him.
38. We hope we have been able to reassure Ms J that the Trust was focused on Mr P and it was working to preserve his life.