Pain relief
19. Mrs U complains the Trust did not administer pain relief to Ms A in a timely manner on two days in late-June 2022.
20. The Trust explained it assessed Ms A’s pain several times a day by asking about her pain score when her routine observations were undertaken. The Trust said it prescribed Ms A two types of strong pain relief medication. It explained that some of medications required two qualified nurses to be available to check and administer the medications. This is due to safety reasons.
21. Section 1.2.8 of the NICE guideline says that if a patient is unable to manage their own pain relief, staff should not assume that pain relief is adequate. It says to ask a patient regularly about pain, assess pain using a pain scale if necessary, and to provide pain relief and adjust as needed. The Code says nurses must deliver care and treatment without too much delay.
22. The records show the Trust prescribed Ms A prolonged release oxycodone twice a day. Prolonged release pain killers gradually release the drug in the body – this was over 12 hours for Ms A. The Trust also prescribed Ms A immediate release pain medication (oxycodone), as needed, every four hours. We can see the Trust also prescribed paracetamol, as needed, every six hours.
23. We have looked at the pain scores the Trust recorded for Ms A on 22 and 27 June. The pain score is out of ten. In general, zero means no pain, one to three is mild pain, four to six is moderate pain, seven to ten is severe pain.
24. On the first day in question, there was no score recorded at 2.11am. The written notes, however, say Ms A complained of pain so the Trust administered pain relief. We do not know what type of pain relief was given at this time.
25. Later that day, the Trust recorded the following pain scores:
• 6.03am – 5 • 2.56pm – 6 • 3.40pm – 2 • 8.09pm – 0 • 9.18pm - 0
26. On the other day in question, the Trust recorded the following pain scores:
• 5.29am – 3 • 10.02am – not recorded • 11.55am - 0
27. The timings for when the Trust administered pain relief is as follows. We will include the last dose given on the day before as the prolonged released oxycodone was scheduled to be administered every 12 hours. We will also label when the Trust administered the prolonged released medication. The timings which are unlabelled are when the Trust administered the immediate release medication.
28. On the night before the first day, the Trust administered prolonged release oxycodone at 11.16pm. On the first day, the Trust administered pain relief at 9.22am (prolonged release), 4.23pm, 5.57pm, and 10.17pm (prolonged release).
29. On the night before the second day, the Trust administered immediate release oxycodone at 6.24pm and then prolonged release oxycodone at 11.44pm. On the second day, the Trust administered pain relief at 3.07am, 9.53am (prolonged release), 2.13pm, 6.23pm, and 9.36pm (immediate and prolonged release).
30. The records show that there were no significant delays in Trust administering the prolonged release medication. The Trust administered this medication regularly, every 12 hours or so. The Trust’s actions here are in line with the NICE guidelines and the Code.
31. In terms of the immediate release medication (oxycodone and paracetamol), we compared when the Trust administered this with the pain scores.
32. When Ms A scored five at 6.03am, this was coming to the end of the effects of the prolonged release medication from the night before. The records show the Trust did not administer immediate pain relief at this time. The first dosage of pain relief Ms A received on 22 June was at 9.22am. This is approximately three hours after the pain score of 5.
33. Our nursing adviser says it was understandable, although unfortunate, that pain relief medication was not administered in a timely manner. They explained this could have been because of other priorities or emergencies on a ward which require immediate attention. We also acknowledge that as this was a controlled medication, it needed two qualified nurses to be able to administer the medication.
34. That said, we acknowledge the Trust taking three hours to administer pain relief is a long time to be in pain. This is not in line with the NICE guidelines and the Code as it did not provide pain relief in a timely manner and as needed.
35. Ms A scored six on the pain scale at 2.56pm, then 2 at 3.40pm. However, the Trust did not administer pain relief until 4.23pm. The Trust administered paracetamol at this time. There is a delay here of approximately one hour and 30 minutes. The Trust then administered immediate release oxycodone at 5.57pm.
36. We acknowledge the Trust’s explanation in paragraph 20 and the advice from our nursing adviser, there can be delays in administering medication. With controlled drugs, like oxycodone, two members of staff are needed to administer this drug.
37. Regarding the later delay on the first day, we think the Trust administered the pain relief here without too much delay. The Trust’s actions here are in line with the NICE guidance and the Code.
38. Later on, the Trust changed Ms A’s prescription for immediate release oxycodone from every four hours to every two hours.
39. Ms A scored 3 at 5.29am on the second day. This was around the end of the effect of the immediate release oxycodone the Trust administered at 3.07am. However, the prolonged released oxycodone had only been administered at 11.44pm the previous night, so this should have still been providing some pain relief.
40. The Trust administered the next pain relief (prolonged release oxycodone) at 9.53am. Our nursing adviser also explains that the delay in administering medication here is not a significant delay. The Trust’s actions here are also in line with the NICE guidelines and the Code.
41. Overall, there is a failing here in the three-hour delay of the Trust administering pain relief to Ms A on 22 June. We will consider the impact of this later in the report.
Personal care
42. Mrs U complains the Trust did not attend to Ms A’s request for help with her personal care in a timely manner in a week in late-June.
43. The Trust says it looked into this issue and apologised Mrs U felt the Trust did not attend to Ms A’s personal care needs in the way she should have been.
44. The NICE guidance says healthcare professionals should ensure the patient’s personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. It also says to ask patients who are unable to manage their personal needs what help they need, and to address these needs at the time of asking. The Code says nurses must keep clear and accurate records relevant to their practice.
45. On the day before the week in question, the records show the Trust assessed Ms A as being independent with her bathing needs and mobility. This included walking to the toilet independently. Furthermore, it also noted in Ms A’s daily care plan that she was independent with her hygiene needs. The Trust noted this every day for this week.
46. This changed on the last day of that week. The records show Ms A required assistance (minimal) from one to two members of staff with walking while using a walking aid. This was also the case for toileting and bathing (assistance of one or two staff members). The Trust notes Ms A could still walk to the toilet. However, the records still state that Ms A only required minimal assistance overall.
47. If a patient is deemed to be independent with their caring and personal needs, we would not expect the Trust to document each occasion in the records. When a patient’s care needs changed, as it did for Ms A at the end of the week, where she needed assistance of one or two staff members, we would expect this to be in the records.
48. There is nothing in the records which documents when Ms A requested help with her personal care. There is also nothing to show whether there were any occasions where Ms A had not been able to make it to the toilet and her bowels had opened.
49. Mrs U explained to us that her sister was able to initially visit the toilet unaccompanied. However, as her condition deteriorated and she was attached to an intravenous (IV) drip and oxygen, this impeded her ability to go to the toilet independently, especially at short notice. She explained that it sometimes led to Ms A not making it to the toilet in time. Mrs U said this happened at the start of the week and on another occasion in the week.
50. Mrs U explains that there were occasions where visitors were helping Ms A to the toilet, wiping her, and bathing her.
51. The Trust reviewed Ms A’s personal needs each day on the week in question. This is in line with the NICE guidance. In terms of the events Mrs U has said happened to her sister, these are not in the records. If Ms A’s visitors did attend to her personal care needs, we think the nursing staff should have recorded what personal care the visitors provided. Especially as personal care of a patient is a fundamental part of nursing.
52. In terms of record keeping, we do not think the Trust followed the Code as the incidents Mrs U describes are not within the records when they should have been.
53. Overall, on balance, we think there are failings here. Whilst the Trust initially assessed Ms A, in line with the NICE guidance, it also seemingly did not attend or address her needs when needed. This is evidenced by what Mrs U has said about what happened to her sister regarding her personal care.
54. Without any records from the Trust to say whether it did help with Ms A’s personal care, or that Ms A’s visitors helped, we are inclined to give more weight to Mrs U’s account of what happened.
55. We think the Trust has failed to act in line with the NICE guidance when providing Ms A personal care, and with the Code in relation to record keeping. We will consider the impact of these provisional failings later in the report.
C. diff
56. Mrs U complains the Trust did not enough to prevent Ms A from catching c. diff and failed to adequately treat this.
57. The Trust explained that when it diagnosed Ms A with c. diff it treated her with a tenday course of vancomycin (antibiotic). This settled Ms A’s symptoms and her infection markers decreased. The Trust said that despite its best efforts to prevent the c. diff infection from reoccurring, Ms A developed symptoms consistent with recurrent c. diff. It said this was despite it taking all appropriate precautions to prevent this. The Trust said it treated Ms A in a timely manner with antibiotics.
58. The GMC guidance says doctors must adequately assess a patient’s conditions and promptly provide or arrange suitable advice, investigations or treatment where necessary.
59. The DoH guidance outlines steps that an NHS organisation can take to prevent c. diff through isolation. It says patients with potentially infective diarrhoea (at least one episode) should ideally be moved immediately into a single room. Stool specimens should then be sent immediately for c. diff toxin test.
60. For patients with confirmed cases of c. diff, the DoH guidance says patients should be transferred to a single room, or isolation ward as soon as possible after diagnosis. The patient should remain isolated until there has been no diarrhoea for at least 48 hours, and a formed stool has been achieved.
61. In terms of treating a patient who has an active c. diff infection, the c. diff guidance says to offer an oral antibiotic to treat the infection. It also provides guidance as to what type of antibiotic to prescribe. The first-line antibiotic for a first episode of c. diff infection is 125mg vancomycin four times a day for 10 days. For a further episode of c. diff infection within 12 weeks of symptom resolution, it says to prescribe 200mg of fidaxomicin twice a day for ten days.
62. In early-May during Ms A’s first admission to the Trust, the Trust diagnosed Ms A with a c. diff infection. In the note confirming this infection, it said for the clinicians to discuss with microbiology department about the treatment for this. The note also indicated that Ms A was already being nursed in a side room.
63. The Trust referred Ms A to the microbiologist to discuss the positive c. diff sample. The note of the advice from the microbiologists’ advice said that usually a ten-day course of antibiotics would be prescribed. The advice goes on to say that if Ms A’s bowel habit had returned to normal without treatment, treatment may not be needed.
64. The day after the c. diff diagnosis, the notes indicate Ms A’s c. diff symptoms were improving. The next day, the doctor noted Ms A was not complaining of diarrhoea and they had discussed with the microbiologist that Ms A did not require antibiotics.
65. The Trust’s actions here are in line with the GMC guidance. The Trust sought advice from a microbiologist regarding the positive c. diff sample and whether to start prescribing antibiotics. The Trust followed the microbiologist’s advice - as Ms A’s symptoms started to improve, it did not start antibiotics. In terms of the DoH guidance, Ms A was already being nursed in a side room.
66. Ms A was re-admitted to the Trust only a day after it discharged her in mid-May. The Trust decided to start Ms A on antibiotics due to an increase in her white cell count. An increased white blood cell count can indicate an infection. The Trust started Ms A on a ten-day course of 125mg of vancomycin. The note also indicates that Ms A was in a side room.
67. The Trust’s actions here are in line with the c. diff guidance and the DoH guidance.
68. The Trust transferred Ms A to a side room at the different hospital within the Trust. This was because the Trust was still treating Ms A’s c. diff infection. The notes show Ms A’s symptoms had improved following the course of antibiotics.
69. The notes do not say whether the Trust moved Ms A from a side room at this point. However, as per the DoH guidance, patients should remain isolated for reasons as outlined in paragraphs 59 and 60.
70. A day or so after Ms A had completed the first course of antibiotics for her c. diff infection, the Trust reassessed whether Ms A required antibiotics again. This was due to Ms A reporting loose stools and stomach pain. These are common symptoms of a c. diff infection.
71. As such, the Trust prescribed a different type of antibiotic to what it had prescribed for Ms A previously. The Trust prescribed 200mg of fidaxomicin, twice a day for ten days. We can see in the prescription charts that the Trust administered this as in line with the c. diff guidance.
72. The notes also indicate that the Trust had paused Ms A’s long-term prescription of omeprazole. This was the case for both the first time the Trust diagnosed Ms A with a c. diff infection, as well when the infection reoccurred. The NHS.uk website explains taking medication like this can increase a person’s chances of developing a c. diff infection.
73. Our nursing adviser explained Ms A was at high risk of developing c. diff. She had previously had a c. diff infection and had been taking antibiotics, had chronic liver disease and had been in hospital for some time. These are also factors which the NHS.uk website says can increase a person’s chance of developing a c. diff infection.
74. Based on the evidence, the Trust acted in line with the c. diff guidance and the DoH guidance. The Trust kept Ms A isolated in a side room, and it treated her with antibiotics in line with guidance.
75. There are no failings here. We hope our explanations here reassure Mrs U that her sister did receive treatment for her c. diff infection, and that the Trust acted in line with the relevant guidance.
Impact
76. We have found failings in:
• in the three-hour delay of the Trust administering pain relief to Ms A on one day in late-June • the Trust not attending to Ms A’s request for personal care in a timely manner, and the lack of record keeping in relation to personal care.
77. Mrs U says that delay in providing pain relief for Ms A meant she was often left in unnecessary pain and agony, especially when she had requested immediate pain relief. Mrs U says it was very upsetting to see her sister in a lot of pain.
78. As a result of the failing in providing pain relief, we think Ms A would have unfortunately experienced pain longer than she should have been. We understand this would have been upsetting for Mrs U to witness.
79. Mrs U says her sister felt humiliated ‘about having her most personal care need exposed, rather than being handled in a sensitive and dignified manner’. She says the situation was degrading to Ms A.
80. As a result of the failing in providing timely personal care, we acknowledge Ms A would have felt humiliated during those times. Again, we understand how difficult and distressing it would have been for Mrs U to witness this.
81. Overall, Mrs U says she had been significantly impacted by the poor care provided to her sister, and the Trust has caused her so much hurt and distress. We recognise the failings we have identified in the care provided would have contributed to this.
82. In its response to Mrs U’s complaint, the Trust apologised that it could not administer Ms A’s pain relief in a timely manner. It explained that it fed back this incident to the team on the ward. In terms of personal care, the Trust said that the Matron and Senior Sister on the ward shared the importance of answering call bells in a timely manner.
83. We think the Trust can do more here to put things right.