Management of back pain
14.Mrs A says that Mr B’s back pain was managed inappropriately when he was in hospital including being denied injectable pain relief.
15.We are sorry to hear about the amount of pain Mr B was in when he was in hospital. This must have been distressing for him and for his family to witness. Having considered the relevant records, our orthopaedic adviser says Mr B’s back pain was managed appropriately by the Trust throughout this episode of care as he was constantly under the management of the pain team who were monitoring his issues. Also, Mr B had relevant consultations throughout with the orthopaedic and neurosurgery teams who considered his pain symptoms when deciding on the care they provided to him.
16.As for being denied injectable pain relief, we note from the records that Mr B requested this, and we can understand why Mrs A is concerned and upset that her father did not receive it. Unfortunately, the records indicate that Mr B was on an already oversubscribed outpatient waiting list for a painkilling injection, but he sadly died before an appointment could be arranged.
17.Nevertheless, the Trust said in its complaint response that no injection (which was potentially risky) of any sort would have improved Mr B’s function, so there was no definite clinical basis for an injection to be expediated, even if this had been possible for Mr B.
18.Recommendation 1 of the NOGG guidance states: ‘Administer analgesia orally rather than parenterally whenever possible. Pain should be regularly reviewed, and analgesia titrated up or down according to pain intensity and side effects, with use of the weakest effective agent for the shortest possible time (Strong recommendation).’
19.The Trust had tried to manage Mr B’s pain throughout this episode of care with medication such as Oramorph and Morphine which are powerful analgesia, in accordance with the NOGG guidance. Although it is unfortunate this was not achieved, our orthopaedic adviser says the analgesia given to Mr B for his symptoms was appropriate in accordance with advice from the pain team.
Spinal fracture diagnosis
20.Mrs A says there were delays in the Trust diagnosing Mr B’s spinal fracture.
21.Our orthopaedic adviser says the Trust diagnosed Mr B with a spinal fracture during his second hospital admission. During Mr B’s first admission from 7 December 2022, he had a CT scan and x-rays, but no fracture was identified. On Mr B’s second admission to hospital from 22 December 2022, he had a CT scan which showed a suspected fracture of his spine. An MRI scan was carried out, but our orthopaedic adviser says this proved to be inconclusive for any fracture or infection.
22.A second MRI scan carried out on 11 January 2023 confirmed that Mr B had a spinal fracture, so this was the point that he was diagnosed with a spinal fracture.
23.We have considered if there was any unnecessary delay in the Trust making this diagnosis. The NICE guidance on Spinal injury: assessment and initial management states:
‘Suspected thoracic or lumbosacral column injury only (children and adults)
1.5.9 Perform an X-ray as the first‑line investigation for people with suspected spinal column injury without abnormal neurological signs or symptoms in the thoracic or lumbosacral regions (T1–L3).
1.5.10 Perform CT if the X‑ray is abnormal or there are clinical signs or symptoms of a spinal column injury.’
24.It is noted from the records that Mr B was in and out of hospital during this episode of care. During his first admission, our orthopaedic adviser says appropriate investigations such as a CT scan and x-rays were carried out in accordance with the NICE guidance, but they did not show any fracture. Mr B was discharged on 19 December 2022 with adequate pain control as per advice from the pain team. Further appropriate investigations including CT and MRI scans were carried out during Mr B’s second hospital admission in accordance with the NICE guidance, and these helped to diagnose his spinal fracture.
25.In summary, diagnosis is not always reached immediately especially if there are some conflicting results, and further investigations must be carried out. In Mr B’s case, we do not consider there was any unnecessary delay in the Trust diagnosing him with a spinal fracture.
Morphine administration and medical review
26.Mrs A says after Mr B arrived at hospital on 22 December 2022, he was administered morphine that left him unresponsive for 3 days and in need of a medical review. Mrs A wants to know what the outcome of the medical review was.
27.After Mr B arrived at hospital on 22 December 2022, our physician adviser says his blood test results showed his kidney function was significantly impaired with an eGFR of 24 (this is a rough approximation to the percentage of kidney function). This was similar to his previous blood results available for the doctors to see, with his eGFR being 26 on 7 December 2022.
28.Mr B’s observations taken at 00:22 on 23 December 2022 included a respiratory rate of 20 and him being alert – i.e. he was not already overtly opiate toxic before the morphine was given in hospital. It was noted at 01:09 that he was “grunting in pain.” The doctor had not seen him in the Emergency Department at this point, but the triage nurse did get a prescription for morphine which our physician adviser says is common practice. The dose of morphine given (5mg) was around 2 hours after the previous intravenous doses (four doses of 2.5mg) which were administered in the ambulance on the way to hospital.
29.Our physician adviser says the Trust’s dose of morphine was reasonable at this point, even accounting for Mr B’s impaired kidney function. This leads to slower removal of morphine and its metabolites (what it is broken down into by the body), so the level can build up. The amount of morphine needed to reach a level to treat the pain is not particularly affected by the kidney function; it is more the ongoing dosing that would need to be reduced.
30.We appreciate that Mr B was in significant pain at this point which must have been distressing for him. There were no signs that he was opiate toxic already at that point. The CEM guidance states that intravenous morphine 0.1 to 0.2 mg/kg can initially be used. The records indicate that Mr B’s weight was 99Kg which our physician adviser says equates to a 19.8mg dose of morphine.
31.As we have said, Mr B had received 10mg of intravenous morphine in the ambulance, so even with an additional dose of 5mg at hospital, this was not excessive for him. It is noted from the records that Mr B became drowsy after being given morphine. Unfortunately, when Mr B went to x-ray, our physician adviser says he became unresponsive which must have been concerning to witness, but he was treated with Naloxone (the antidote to morphine) with good effect.
32.Having considered the relevant records, our physician adviser says Mr B was not unresponsive for three days after being given morphine. His regular observations during this time indicated that he was alert. He did go unresponsive while in x-ray and needed Naloxone which improved his condition, and then less morphine was given thereafter, along with a pain team review. This appears to be the medical review referred to by Mrs A. Our physician adviser says there were no concerns about Mr B after this review, in relation to the impact of the morphine he had been given, and there was reasonable treatment of his pain, thereafter, balancing the risks.
Inappropriate discharges
33.Mrs A says that Mr B was inappropriately discharged from hospital by the Trust on 19 December 2022 and 25 January 2023.
34.We note from the records on 18 December 2022 that Mr B had not slept much as he was in constant pain, despite receiving pain relief. There is a documented discussion with Mr B’s family, with them being concerned about his mobility and wanting him home, where they felt he would recover better. There were further discussions where it was explained to his family that there was a balance between pain relief and drowsiness.
35.On the ward round on 19 December 2022, it is noted that Mr B was still in significant pain, and his C-reactive protein (infection blood test) was rising. A four times a day care package was to be put in place and the family opted to look after him until such time it was. His vital signs were stable at the point of discharge. It was noted that Mr B was in pain on discharge, but his son was still happy for him to be discharged to home. The records indicate that Mr B saw a consultant prior to this discharge, but there is nothing documented to rationalise the decision to discharge.
36.Based on the records, our physician adviser says Mr B’s condition was stable by the point of discharge, so there was no truly compelling reason to keep him in hospital. It is also acceptable and not unusual for a family to provide care at home while a formal package of care is arranged. Overall, we consider it was a reasonable decision by the Trust to discharge Mr B on 19 December 2022.
37.In terms of Mr B’s second discharge on 25 January 2023, our physician adviser says Mr B had been found to have an L2 (lower back) fracture, but he was able to walk around (if able due to pain) with a brace and to have outpatient follow up for this, and a pain team referral. A Multi-Disciplinary Team (MDT) plan was put in place for Mr B to go home and be nursed in bed. This was part of a package of care and community therapy referrals, and suitable equipment was being ordered. Arrangements were made with district nurses for Mr B’s catheter care.
38.At the point of discharge, our physician adviser says that Mr B’s observations were stable, and appropriate plans were in place to care for him at home with support from his family. Therefore, we consider it was a reasonable decision by the Trust to discharge Mr B on 25 January 2023.
39.After a review by the heart team, Mr B had to be readmitted to hospital on 7 February 2023. During this admission, our physician adviser says Mr B became frailer. His heart and kidneys were failing despite appropriate medical management (including advanced measures like albumin infusion and furosemide infusion). The protein level in his blood was falling. He was bedbound. His sodium was low which is an adverse prognostic sign. Mr B’s food intake was also noted to be minimal.
40.Our physician adviser has added that Mr B had a background of high blood pressure, an abdominal aneurysm (abnormal widening of the main artery) and back problems. His pain management was an ongoing issue, alternating to being drowsy and in pain. Unfortunately, there are no perfect solutions to this, with opiate-based pain killers potentially building up to kidney failure and some other pain relief such as Ibuprofen not being possible to give due to his heart and kidney issues. On 13 February 2023, Mr B was noted to be less drowsy but was in pain again.
41.Blood tests had shown that Mr B’s white cell counts, and C-reactive protein (markers of infection) had risen, but our physician adviser says these rises were modest. Mr B’s observations timed at 10.22am on 14 February 2023 were reasonable. The nursing staff had documented that Mr B was ‘chesty,’ and they had performed some suction to remove his secretions. The plan from the ward round was to treat Mr B for pneumonia, but he suddenly deteriorated and sadly died. We appreciate this was unexpected and the news came as a terrible shock for Mr B’s family who were left devastated by his death.
42.This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.