Pain relief
17. Mrs R complains the Trust did not give her a PCA pump after her operation, as her urologist had told her she would be given one. Mrs R said her urologist told her because the complex ureteric stent and catheter system was known to cause high amounts of pain, she would be given a morphine pump.
18. The Trust has apologised that Mrs R was not given enough pain relief. It said there is no record of a request from gynaecology to provide a PCA after the procedure. It also explained when Mrs R was given pain relief.
19. It said Mrs R was given intravenous doses of morphine (a strong opioid painkiller used for severe pain and given through the veins), tramadol (a strong opioid painkiller used for severe pain) and paracetamol between 12.15pm and 2pm immediately after her surgery. After her transfer to the ward at 2.30pm it gave regular doses of paracetamol, ibuprofen (a non-steroidal anti-inflammatory drug (NSAID)) and codeine (an opioid painkiller used for mild to moderate pain) with oral morphine as needed.
20. The Trust said it gave Mrs R codeine at 3.07pm and ibuprofen at 3.35pm. As Mrs R continued to complain of pain, it gave oral morphine at 5.40pm.
21. When Mrs R was still in pain, the nurses asked for a doctor review and they prescribed a PCA pump. This was given at 9.49pm.
22. The Trust apologised that Mrs R was not prescribed the PCA immediately after surgery as she had expected, and attempted to reassure her that the prescribed medication was given in good time and nurses asked for medical review when it was clear that pain relief was not effective.
23. The Trust’s second complaint response explained it is normal procedure for the anaesthetist to arrange post-operative pain relief. The Trust said there is no record of a discussion about using PCA and, in line with its normal practice, the plan was to give pain relief including opiates, local anaesthetics, NSAIDs and paracetamol.
24. The Trust also said Mrs R was moved to the ward as the pain relief given in recovery seemed to be controlling her pain. The nurses on the ward gave the prescribed medication. When it was clear this was not effective, they gave more morphine as per prescription. When the pain continued, they requested a doctor to review and consider alternative pain relief. The doctor prescribed an injection of morphine which was given at 5.40pm. At the same time, a consultant was asked to approve the PCA pump. This was agreed and a prescription was written at 7.27pm, but this was checked by the pharmacy and the medication was incorrect and had to be prescribed again. This was finally completed at 9.35pm and the PCA pump was provided at 9.49pm.
25. The Trust explained that nurses cannot give medication that has not been prescribed but wanted to assure Mrs R that the prescribed medication was given in the correct way and, when this was not effective, nurses asked for a review.
26. The Trust also said it has shared feedback with the gynaecological team to avoid future delays by discussing the need for a PCA and early prescribing when this is needed.
27. In the second response, the anaesthetist said they checked the prescription records and the paracetamol and tramadol were not prescribed after the PCA was removed. The PCA was not renewed, as the Trust thought Mrs R had enough pain relief and this was not recognised at the review on 17 September.
28. The Trust has apologised that this was not prescribed as documented. It has asked the gynaecology team to reflect on these findings and make sure that planned medications are prescribed. The Trust also asked the pain team nurses to train ward nurses to increase their knowledge of pain management. This is to make sure nurses can recognise when a prescription for an increased dose has not been issued.
29. The Trust has apologised for the lack of pain relief after the removal of the PCA and that Mrs R’s pain was not better managed at that time.
30. There is no record of a post-operative pain relief plan in the surgical or anaesthetic records.
31. The records confirm that Mrs R was given morphine in post-operative recovery at 12.15pm and tramadol at 1.30pm. She was also given intravenous paracetamol at 2pm and was discharged to the ward at 2.30pm.
32. After arrival to the ward, the records show Mrs R continued to complain of pain and was given ibuprofen at 3.35pm and codeine at 3.07pm and 7.15pm.
33. Despite this, Mrs R continued to feel pain and medical staff reviewed her and prescribed Oramorph at 5.40pm. Her pain persisted and she was given morphine at 6.58pm.
34. The records show that after Mrs R’s pain continued, medical staff got a review from the gynaecology consultant who agreed a PCA pump should be started. This medication was prescribed at 9.35 and started at 9.49pm.
35. The records confirm that the endometriosis clinician reviewed Mrs R on 16 September. She was continuing to use the PCA, and was prescribed intravenous paracetamol, ibuprofen, tramadol, cyclizine (anti-sickness medication), sodium docusate (a laxative) and lactulose (used to treat constipation). Staff planned to take down the PCA and trial Mrs R without a catheter, if appropriate, the next day.
36. The records show that when the endometriosis clinician returned on 17 September the PCA had been taken down, although Mrs R continued to complain of pain. The records show she stayed on the same prescriptions of pain relief and Oramorph was to be used as needed. We note the Trust has said this was not the case, as the prescriptions were never given.
37. Mrs R was discharged on 18 September. We discuss this process later in the report.
38. Our adviser said they would not consider a PCA to be prescribed as routine or common practice after the procedure Mrs R had. They said there is no specific guidance for this, so we have consulted NICE guidelines on peri-operative care in adults.
39. This guidance states that a multimodal approach (using different types) to pain relief should be offered. This should combine pain relief from different classes to manage post-operative pain.
40. This guidance also states that an oral opioid should only be offered if immediate post-operative pain is expected to be moderate to severe. For people when patients cannot take oral opioids, a choice of PCA can be offered.
41. NMC guidance states that nurses must make a timely referral to another practitioner when any action, care or treatment is needed.
42. We can see no evidence in the records that a PCA was planned for post-operative pain relief.
43. We understand that Mrs R was told she would be given a PCA and we accept it would be very distressing to expect treatment and not get it. There is no record of this plan and our adviser has said it would not be usual practice, so we have not seen a sign of a failing in the Trust not giving Mrs R a PCA immediately.
44. We can see that Mrs R was given pain relief after her operation and continued to be prescribed pain relief throughout her admission. When this pain relief was not effective, nurses escalated this to a medical team for review. The Trust has acknowledged that there was a failure to prescribe enough pain relief after the PCA was removed. The Trust explained actions it has taken to prevent this from happening again and has offered an apology.
45. We have considered the NHS Resolution guidance and this says an apology should show sincere regret that something has gone wrong and should be tailored to the individual.
46. We have also referred to our Complaint Standards. These standards state that organisations should view complaints as an opportunity to develop and improve services. They also state that organisations should openly identify where things have gone wrong, or where services have had an unfair impact, and take responsibility for this.
47. We are sorry to hear about Mrs R’s experience and the pain she felt. The response from the Trust offers a sincere apology and acknowledges the distress its actions caused. It states that the complaint has been used to provide feedback to the relevant department and to make sure this does not happen in future. We think this is right to put right the impact of what happened, and we do not think the Trust needs to do anything more.
Behaviour of ward staff
48. Mrs R complains the nurses on the ward were not supportive and made inappropriate comments. She also complains they made her get out of bed despite being in pain.
49. The Trust said the nurses were aware of Mrs R’s pain and made every effort to help. The Trust apologised that the language used was upsetting and it says the feedback has been discussed with the nursing team.
50. In the second response, the Trust explained that the nurses asked Mrs R to get out of bed as moving is an important part of recovery. It said the nurses should have explained the reasons for asking her to get up and they should have made sure her pain was manageable when asking her move. It apologised that Mrs R was pushed to get up despite being in pain and for the distress this caused. It also said it has provided training on recognising and managing pain and staff were reminded to communicate clearly the reason for any activity.
51. The Trust has given a sincere apology and acknowledged the distress its actions caused. It has given details of how it has provided feedback and created staff training to prevent this from happening in the future. We think this is an appropriate response in line with the Complaint Standards. We are sorry to hear about Mrs R’s experience and hope this statement has put her mind at rest.
Discharge process
52. Mrs R says she was expecting to be discharged in the morning, but she was not seen by a doctor until 4pm, which was two hours after she had been moved to the waiting area because the nurses needed the bed. She was discharged five hours later, during which time she did not receive any care and had to keep asking for food and pain relief. A fit note for her employer (to give advice about her fitness to work) was also not completed.
53. The Trust said Mrs R was moved to a seated waiting area once she was medically fit for discharge. She was to wait for final checks, outpatient bookings and any paperwork or medication. It apologised that this took longer to arrange than she expected and for the distress and inconvenience caused.
54. The Trust has asked for staff to make sure patients are fully informed of likely timescales for discharge and to keep them updated.
55. The Trust also apologised that Mrs R was not given any care or food while waiting to be discharged and that she was not given a fit note immediately. It also apologised that when the fit note was posted to her, it was dated incorrectly.
56. We think the Trust’s response is appropriate and in line with the Complaint Standards.
57. We are satisfied the Trust has done enough to put right how Mrs R was affected. This does not take away from Mrs R’s experience.