Failure to provide pain relief
19. Ms A complains that the Trust failed to provide her mother with any pain relief either prior, during, or immediately after her pelvic binder was fitted.
20. Our Adviser explained that there is no specific guidance regarding offering pain relief either before or after such a procedure. Indeed, the procedure’s intention is to provide stability to a fracture which normally relieves pain but our Adviser clarified that this is not always the case. It is clear from Ms A’s account that, very unfortunately, Mrs A found the procedure painful and distressing. The clinical record merely states that she was not co-operative with the procedure indicating that, as Ms A says, she struggled to tolerate it.
21. The NICE Guidance is applicable here. This says that when managing a hip fracture staff should offer paracetamol every six hours unless there is a reason this should not be given. It also states that if this does not provide sufficient pain relief then staff should consider offering additional opioids to help manage the pain.
22. The Trust acknowledged that the level of pain relief provided to Mrs A was not to the standard it would have expected. She was given IV paracetamol by the ambulance crew at roughly 10.30am that morning meaning she should have received more at around 4.30pm. Instead, she was not given any pain relief until 9pm. This fell far short of what should have happened and we currently consider that it amounted to a failing.
23. The Trust has accepted this was not in line with the NICE Guidance. There was clearly a delay in Mrs A being given appropriate pain relief. We have gone on to consider the impact of this.
Impact of the delay on her mother
24. Ms A says the hip binder procedure caused her mother a great deal of pain and distress. She says her mother remains confused about the events of 20 August 2023 following the hip binder procedure. She believes what happened caused her mother’s cognitive and physical abilities to decline resulting in her requiring much more care than beforehand.
25. Ms A has clarified that her mother was not in any pain prior to the fitting of the hip binder. She has explained that the pain only began once the binder application started without the adequate level of pain relief. This was the point, she says, where her mother’s distress began rather than upon admission to the Trust.
26. Having reviewed the Trust’s records, we can see her admission notes highlight Mrs A had pain in her back, left hip, left forearm, and left elbow following her fall. This pain was following the previously administered IV paracetamol that, as we have set out, was the only pain relief she received until much later that day.
27. We have no reason to doubt that Ms A’s mother’s pain may have likely been worsened during the binder application procedure but, given the evidence, we cannot say that her pain was absent entirely until this point. As set out earlier, one of the intentions of applying a pelvic binder is to relieve pain following a fracture but this may not always be the case as, unfortunately, appears to have been the case for Mrs A. Indeed, our Clinical Adviser has explained that the application process can be painful in and of itself.
28. We considered Ms A’s belief that her mother’s cognitive and physical abilities have declined as a direct result of her experience at the Trust. Our Adviser explained that Mrs A’s reported decline appears to have been in keeping with what would be expected following a significant hip fracture at her age.
29. As well as this, the clinical notes set out that Ms A had had raised concerns regarding her mother’s cognitive abilities upon her arrival at the emergency department. Mrs A’s clinical records show Ms A informed staff that, over the last year, her memory had been getting worse and she had been getting confused more easily. This obviously preceded the pelvic binder and suggests her cognitive abilities had been declining for a period of time even before the procedure.
30. We found that the delay in providing pain relief meant Mrs A’s pain was not managed as well as it should have been on the day of her admission. This was an injustice to her and we have no doubt how upsetting this must have been. It is of course incredibly unfortunate to hear that she went on to decline following these events. Sadly, that appears to be a result of her injuries and a continuation of a decline that had seemingly already started by this point as opposed to not being given timely pain relief on admission.
31. Our Principles state that where failings have been found and accepted, organisations should consider offering a remedy to those who have suffered injustice or hardship as a result of that poor service. Usually a remedy would be one or more of an apology, service improvements, or, where appropriate, financial compensation.
32. In its response to the complaint, the Trust acknowledged and apologised for this delay. It explained that it had also reminded both the emergency department team and the nursing team of the importance of checking pain levels and offering pain relief as part of the assessment and care provided. It has also implemented a Trauma Pathway Coordinator for the emergency department to support improvement in staff skills and knowledge surrounding immediate care pain relief.
33. So, the Trust has already provided the apology and implemented the service improvements that Ms A understandably hoped for. We went on to consider whether it should pay compensation to recognise the impact of the delay in giving her pain relief.
34. The Scale sets out how we consider the differing levels of severity a complainant may have experienced. Level one of the Scale includes a level of short-term pain that usually lasts no more than a few days and can be managed by non-prescription medication (such as paracetamol). At Level one, we would usually consider an apology to be an appropriate remedy.
35. We do not wish to minimise the pain Mrs A experienced as a result of her injuries or that may have been exacerbated by the hip binder procedure. We recognise that she should have had pain relief to help her with this and that not having any meant she likely felt more pain than she would otherwise. We think this amounted to an impact at level one of the Scale.
36. This means we believe what the Trust did was in line with our Principles and we have not, therefore, recommended any further action.
Impact of the delay on Ms A
37. Ms A has described in detail how she was made to feel after seeing the pain her mum was in during her admission.
38. We recognise that it was undoubtedly a very traumatic and difficult experience for Ms A to see her mother in pain following a significant injury. From the comments made by Ms A, we also know that the binder application procedure was difficult for her to witness due to her mother’s pain and distress. We can understand that this can have a lasting impact on anyone who may experience anything like this.
39. As an extension, we can also accept that it may impact on her feeling towards the medical profession in general as well as increasing her own levels of anxiety and responsibility for being there for her mother. The entire experience would have been difficult for anyone involved and we can entirely appreciate Ms A’s perspective coming out of it.
40. We can only hold the Trust accountable for the impact its actions had. It is incredibly difficult, if not impossible, to separate the impact of her mother’s treatment for her injuries and the impact of her not receiving timely pain relief on Ms A’s perception of these events. In other words, we cannot say that not providing pain relief is the sole, or even a significant contributing factor, to Ms A feeling this way.
41. We accept that, as we set out earlier, it is possible that the binder procedure may have been less distressing had the Trust given Mrs A the pain relief it should have at the time it should have been administered. However, the procedure can be a painful one and we simply cannot say that things would have been different even with timely pain relief - Mrs A was likely always going to be in a lot of pain and distress as a result of her injuries and the subsequent treatment. As already noted, this would be incredibly difficult for anyone to have to witness.
42. We believe it is difficult to say even on balance that the impact Ms A is claiming was caused solely by the delay in providing medication rather than also as a result of what was an extremely distressing situation. Given this, we have not seen any cause to recommend the Trust take further action to and put things right.