Pain management
21. Mrs C is concerned her husband’s pain was not managed appropriately whilst in hospital. She says Mr R also took regular high doses of pain relief at home and she complains regular doses of this was missed during his admission.
22. When Mr R was admitted to the Trust on 5 April 2021, he had a pre-admission prescription of 5 to 10 mg of oramorph (an opiate based painkiller) to be taken when required every four to six hours. Mr R also had a pre-admission prescription of co-codamol (a combination of paracetamol and codine used for pain relief, which is also opiate based) to be taken when required.
23. The records show when Mr R was admitted on 5 April 2021, 5mg of oramorph was prescribed by the Trust to be taken as required every two to four hours.
24. We can see Mr R was given regular doses of oramorph on 6 and 7 April and in total received 20mg per day.
25. On 8 April, Mr R received one dose of 5mg oramorph in the evening. On 9 April, Mr R did not receive any dose of oramorph.
26. On 10 April, Mr R was given 15mg of oramorph and 20mg on 11 April.
27. Throughout the same period he was also given a total 180mg of co-codamol.
28. The BNF says 5-10mg of morphine (oramorph) should be given every four hours according to someone’s response in adults with chronic pain. It also says co-codamol should be given every 4 -6 hours.
29. Our physician adviser said the initial admission prescriptions were in keeping with Mr R’s prescription at home, which was to give both pain relief medications as required.
30. We have thought about whether Mr R’s pain was managed, as his prescription was to be given when required.
31. The NMC says nurses should take appropriate action to reduce or minimise pain or discomfort.
32. The Core Standards for pain management says pain management should be led by a specialist team with appropriate training and knowledge. It also says pain assessment tools should be used and a regular assessment and recording of pain should be carried out.
33. We have looked at the records and cannot see any evidence of pain assessments or monitoring throughout Mr R’s admission.
34. Our nurse adviser told us there is an expectation to monitor someone’s pain levels using a numerical or verbal scale and this will help clinicians to decide if pain relief has been effective or whether it needs to be reviewed.
35. Mrs C also showed us evidence of messages sent to her from Mr R and at 10.37am on 10 April. He told her in was in pain and had asked for morphine (another name for oramorph), but had not yet received any. The records show he was then given 5mg of oramorph at 11.30am.
36. We are so far seeing Mr R was only given 5mg of oramorph on 8 April, which was below what he was used to taking and he was not given any on 9 April. We have seen no evidence the Trust carried out any pain assessments, or considered whether the pain relief that was administered was effective.
37. We consider the lack of pain assessments to be a failing. Having considered the high dose of pain relief Mr R was used to taking, as well as his own statements he was left in pain, we are so far seeing the failure to assess Mr R is likely to have left him in unnecessary pain.
38. We have gone on to make about the recommendations to address the impact of this failing, at the end of this report.
Oramorph on 10 April 2021
39. Mrs C is concerned the higher dose of oramorph on 10 April led to an opiate overdose and caused her husband’s deterioration. She told us an anti-opiate medication was given to reverse the side effects of the oramorph.
40. We can see Mr R was given 10mg oramorph at 11.30am on 10 April. He was given another dose of 10mg of oramorph at 15.50pm. Mr R was given two 10mg doses of oramorph on 11 April at 10.25am and 13.30pm. The last dose was given just under 24 hours before Mr R’s severe deterioration on 12 April.
41. When Mr R deteriorated in the afternoon of 12 April, the Trust gave five doses of naloxone. Naloxone is a medication that can be used to reverse the side effects of opioids in an overdose.
42. The BNF says 400 micrograms of naloxone should be given, then increased to 800 micrograms if there is no response. It also says further doses may be required, however, if there is no response to the medication, the diagnosis should be reviewed.
43. Our physician adviser explained the doses of oramorph given on 10 and 11 April would have been unlikely to have caused Mr R’s severe deterioration. This is because the doses given on 10 and 11 April were in keeping with the prescription Mr R had at home and was used to taking regularly.
44. Our physician adviser also explained naloxone could be used to reverse the side effects of co-codamol, however, the records show Mr R was given a daily dose of co-codamol throughout his admission which did not vary and therefore was unlikely to cause an overdose and sudden deterioration.
45. Our physician adviser told us naloxone is usually given if side effects of an opiate are thought to be the cause of someone’s reduced consciousness level. They also explained naloxone is reasonable to trial, even if this isn’t the definite cause of someone’s deterioration, because the risk of missing opiate toxicity is greater than administering naloxone unnecessarily.
46. We acknowledge Mrs C’s concerns her husband may have been given too much opiate and this was the reason for giving naloxone, however, we have not seen evidence Mr R was given more opiate than he should have been. We also found the Trust tried several other treatments, including broad spectrum antibiotics and broad spectrum steroids to treat Mr R when he deteriorated so suddenly to treat possible causes while staff tried to investigate the cause of his deterioration. This indicates the Trust were not certain Mr R had suffered an opiate overdose, but wanted to rule it out.
47. We hope our report reassures Mrs C that naloxone was given as part of a wide variety of medication to treat all possible causes of her husband’s deterioration.
Communication about Mr R’s deterioration
48. Mrs C complains she was not told about how serious her husband’s condition was and she was shocked to hear about his sudden deterioration.
49. Mrs C told us the last coherent message she received from her husband was at 23.05pm on 10 April.
50. The records show Mr R was seen by a nurse at 5.40am on 12 April, where he was noted to be awake and alert. It is important to acknowledge we do not know for certain how Mr R was at this stage or why he did not send any further coherent messages to his wife.
51. Mr R was assessed and seen again at 11.25am by a gastroenterologist for review and his observations were taken.
52. Mr R was then seen by two doctors at 12.54pm on 12 April and it was noted he was confused and drowsy and he was very unwell. The notes show a discussion was planned to talk about how much care Mr R could be given moving forward. At this stage, Mr R also received various treatments including intravenous fluids, broad spectrum antibiotics, steroids and naloxone.
53. Mrs C has sent us a recording of a phone call she made at 13.01pm. During this call she asked for an update. We do not know from the recording who the staff member was, but they told Mrs C a message would be passed on for a member of the clinical team to call her back.
54. Doctors saw Mr R again at 13.35 and the severity of his condition was noted. He continued to receive emergency treatment.
55. A liver specialist doctor had also seen Mr R and called Mrs C at 14.04pm to explain the severity of Mr R’s condition. We have listened to a recording of the call and we think Mrs C clearly did not know about the severity of her husband’s condition until this point.
56. Mr R’s death was confirmed at 14.50pm, and sadly Mrs C was unable to get to the hospital before he died.
57. There is no specific guidance to say when a family should be updated however GMC guidance says clinicians should communicate with those close to a patient.
58. We have thought about when the earliest opportunity would have been to tell Mrs C about her husband’s deterioration. We can see the Trust was first aware Mr R was deteriorating at 12.54pm. Our physician adviser said at this point, the records show the medical team were carrying out urgent treatment and monitoring Mr R. They said they would expect Mr R’s family to be notified at the earliest opportunity after 12.54pm.
59. We acknowledge that when a patient deteriorates suddenly there is usually a period of time where the situation is assessed and treatment is given. It is very difficult to say when exactly a clinician would have been able to make the family aware of the situation if they are providing urgent treatment.
60. We can see there was a time period of one hour and seven minutes between the Trust realising the seriousness of the situation and telling Mrs C about it. We have considered the Trust were carrying out urgent treatment during this time frame and we have seen evidence the doctor who did call Mrs C with the information, was not directly involved in Mr R’s emergency treatment at that time.
61. We know this delay would have been extremely difficult for Mrs C, especially now knowing her husband was extremely ill at this stage. However, we are unable to say if staff at the Trust could have called any earlier than they did, in light of the emergency treatment Mr R was receiving at the time. We know the Trust did call Mrs C to give information and we hope to provide some reassurance Mr R was receiving emergency treatment at this time.