Pain relief
16. Mrs D arrived at the ED by ambulance just after midday. The crew had administered 5mg of oramorph (pain relief). ED staff prescribed further oramorph at 1.13pm but did not administer this. It prescribed a further dose of the medication at 4.50pm and administered this at 6.45pm.
17. Mrs D’s daughter, Mrs T, was with her mother in ED. She said Mrs D was in unbearable pain during her time in the ED and she repeatedly asked the staff to give her pain relief.
18. In its complaint response, the Trust said, despite its best efforts, it was unable to establish the reason that it did not administer the first dose of oramorph. It apologised for the delay in administering the second dose of pain relief. It did not provide an explanation for this.
19. The BNF says oramorph is recommended four hourly unless the pain is not improving.
20. We have looked at Mrs D’s ED records. The ambulance crew gave Mrs D oramorph on the way to the ED. A nurse assessed her on her arrival and prescribed a further dose of oramorph just over an hour after her admission. The Trust did not administer this. We cannot see any records of Mrs D’s pain score and the notes do not mention she was in severe pain. But Mrs T says Mrs D was in unbearable pain and needed further pain relief.
21. When we look at the evidence, we can see the first dose of oramorph the Trust prescribed was in the four hour window the BNF mentions. But it also indicates a patient can have oramorph more frequently than every four hours if their pain is not improving. Mrs T says her mother was in significant pain and the Trust did prescribe a further dose of oramorph in the knowledge the ambulance crew had done this within the last four hours. It is more likely than not the Trust had decided Mrs D’s pain was not improving and she needed more. But it did not administer this. We do not think the Trust acted in line with the BNF and we have found a failing here.
22. The Trust prescribed the second dose of oramorph at 4.50pm and administered it at 6.45pm. This was almost seven hours after her admission and initial dose from the ambulance crew, five and a half hours after the Trust had first decided she needed further pain relief in the ED, and almost two hours after the second prescription. Our adviser noted that when the Trust administered the second dose of the pain relief, after the two hour delay, this was outside the four hour ‘safe window’ set out in the BNF. We have found a failing here.
23. We next look at the impact of these failings.
24. Mrs T said that before the Trust administered the oramorph at 6.45pm, Mrs D was in unbearable pain. She said she repeatedly asked staff to prescribe her mother more pain relief. She found this incredibly distressing to witness and it still haunts her. She said once the Trust administered the pain relief, Mrs D’s pain reduced and she was more comfortable.
25. When we weigh up the evidence, it is more likely than not that the Trust’s mistakes meant Mrs D was in more pain for several hours longer than she should have been. She should have had oramorph shortly after the Trust prescribed it at 1.13pm and she did not get it until five and a half hours later. From our advice, we know the effects of the initial dose of oramorph that the paramedics gave her will have worn off. We know she had a fracture to her back and the Trust identified she needed strong pain relief because it prescribed this twice. When she got it, it did relieve some of her pain. We also think seeing her mother in pain and repeatedly asking for pain relief for her caused Mrs T distress and anxiety at an already difficult time for her.
26. Lastly, Mrs T thinks the Trust should have given Mrs D stronger pain relief. The RCEM guidance on pain management says that oral analgesia is the starting point to manage moderate to mild pain, subject to reassessment. This is what Mrs D had. Our adviser said the Trust’s only other option would have been intravenous morphine (administered into a vein). They said there is no evidence in the notes to suggest this would have been necessary for Mrs D. Based on the evidence, the Trust acted within the RCEM guidelines here.
Antibiotics
27. Mrs D had a urinary tract infection (UTI) at the time of her admission and was two days into a course of antibiotics that her GP had prescribed. She did not have these with her when she went into hospital and was due a dose. The Trust prescribed doxycycline at 6.35pm, but it did not give it to her.
28. The General Medical Council’s ‘Good medical practice’ says doctors should provide a good standard of practice and care. From the evidence we have seen, we think the Trust fell below that standard when it prescribed Mrs D the antibiotics and did not administer them.
29. We have looked to see what impact this had on Mrs D’s health. She only missed one dose of the antibiotics. Her notes show that her inflammatory markers were not in the high range. Our adviser said on the balance of probabilities, missing a dose of doxycycline is unlikely to have had a negative impact on Mrs D’s health.
30. Mrs T explained that she was already beside herself with worry because her mother was not getting enough pain relief. She knew Mrs D had a UTI and was due her medication. When she did not get it, this only added to Mrs T’s worry. We can see how the Trust’s failure to give Mrs D the antibiotics made an already upsetting time worse for Mrs T.
X-ray
31. Due to Mrs D’s fall at home, the ED department gave her an X-ray. Mrs T says before the Trust discharged Mrs D, it told them that the X-ray was clear. It then contacted them seven days later and said Mrs D had two fractures on her spine.
32. The Trust explained that when an ED clinician arranges for a patient in the ED to have an X-ray, its process is that the clinician will initially review the image to check for abnormalities. Later, a radiology consultant will review the image, complete a formal report and send it to the ED clinician, who will contact the patient and recall them if necessary. This is line with the RCEM guidance on the management of investigation results in the emergency department. And it is what happened in Mrs D’s case. So we have focused on the ED clinician’s review of the X-ray and whether they should have noted the fracture.
33. Our adviser examined Mrs D’s X-ray image and medical notes. They said the X-ray shows some old fractures. There was also new grade 1 stable fracture (compression fracture). This can be very subtle and is not an obvious change. Our adviser also explained it is not uncommon when initially reviewing an X-ray to view such a fracture as old. Based on their knowledge and experience, our adviser did not think the ED doctor missed something that was obvious and that they should have picked up at the time. We have found it was not a failing that the ED doctor did not identify the new fracture.
34. We understand Mrs T was devastated when she found out that her mother had left the ED with a fractured spine. Mrs T says her mother died in pain and this was the Trust’s fault. We are sorry Mrs D and Mrs T went through this. We understand Mrs T thinks the Trust’s mistakes contributed to her mother’s death. Our adviser gave some further comments, which we would like to share. They said the type of fracture Mrs D has is associated with osteoporosis and fragility. The notes show Mrs D had passed her mobility assessment. Based on the BMJ guidance, if the Trust had identified her fracture in the ED, her management would have been no different. For this type of injury, BMJ advises pain relief and early mobilisation.
35. We hope this information reassures Mrs T that, even though the ED doctor did not note the fracture, her mother did not miss out on treatment she should have had sooner.
Complaints process
36. Mrs D died 11 days after her admission to the ED. Mrs T says the complaints process compounded her grief. She complained to the Trust almost two weeks after Mrs D’s death and the Trust responded two months later. She said the response did not provide her with adequate answers to her complaint, was vague and lacked empathy.
37. Our ‘Principles of Good Administration’ say public bodies should communicate effectively and give people information and advice that is clear, accurate and complete. They also say public bodies should treat people with sensitivity. The ‘NHS Complaint Standards’ set out what organisations should do to thoroughly address complaints. They say the organisation should clarify the issues, understand the impact and outcome sought, investigate carefully and provide an appropriate remedy to put things right.
38. The evidence shows the ED team fully investigated Mrs T’s complaint and the clinical and nursing leads prepared the response. It provided a timeline of Mrs D’s care in the ED department and responses to Mrs T’s specific complaint points, including a comprehensive explanation about the X-ray results. It confirmed that Mrs D’s treatment would have been no different if the ED doctor had identified the fracture. The Trust apologised that, despite its best efforts, it could not explain why it did not give Mrs D her medication when it should have. It agreed this was unacceptable.
39. The Trust acknowledged and apologised that the standards of care provided fell below Mrs T’s expectations. It said it would share her concerns with the team to consider how they could improve services during times where the demands on the services are increased.
40. Mrs T is upset and frustrated that the Trust cannot explain why it missed the medication. She feels this shows the Trust was being vague and unempathetic. We can understand this. Mrs T was distraught when she watched her mother in pain, and the Trust cannot explain why this happened.
41. When we look at the response objectively, we cannot say it is a failing that the Trust could not explain why it had missed the medication. It investigated thoroughly, but it simply could not give an answer, and acknowledged this. When we look at the complaint as a whole, we think the Trust dealt with it the best it could in line with the NHS Complaint Standards.
Summary of our findings and what the Trust has already done to put things right
42. On the basis of the evidence we have seen, the Trust failed to give Mrs D pain relief when she needed it. This left her in pain for longer than she should have been. Watching her mother in such pain caused Mrs T significant distress and anxiety. The Trust also failed to give Mrs D antibiotics. While there is no indication this had a clinical impact in her, it added to Mrs T’s distress.
43. We have found that the type of pain relief the Trust prescribed was appropriate and we cannot say the ED doctor made a mistake when they reported on Mrs D’s X-ray. We think the Trust dealt with Mrs T’s complaint in line with the NHS Complaint Standards.
44. The NHS Complaint Standards say organisations should identify suitable ways to put things right for people. Mrs T wanted the Trust to acknowledge what it got wrong and apologise and offer a financial remedy to recognise the impact it had on her and Mrs D. She wanted the Trust to make service improvements.
45. The Trust has acknowledged and apologised for the delay in administering the pain relief and not administering the antibiotics. It has also explained how it will take the learning from the complaint to feed into improvements in its service. These actions are in line with the NHS Complaint Standards. But we think there is more the Trust should do to put things right for Mrs T.