Pain management after procedure
20. Miss O complains the Trust failed to properly manage her pain immediately after the operation. She explained she woke up in recovery ‘in excruciating pain’ and an epidural the Trust gave her had not worked. She explained she asked for pain relief, but this did not reduce her pain, and that the Trust should have given her a morphine syringe driver (a form of PCA).
21. She also explained that she asked a nurse to help her stand up to manage the pain, but this also did not help. We recognise this will have been a very distressing time for Miss O.
22. In responding to the complaint, the Trust explained it was sorry to hear the medication Miss O was given did not control her pain. It explained staff gave Miss O additional pain relief in recovery.
23. The Trust also explained a PCA is not always necessary when a spinal anaesthetic has been used following a hysterectomy. It said that even though there was good evidence the spinal anaesthetic was working, patients can still feel pain. The Trust explained staff tailor the analgesia regime to the patient and there is a much bigger emphasis on keeping a patient mobile with as few drips and infusions as possible, to help prevent complications.
24. When we investigate a complaint, we first consider what should have happened. We do this by looking at what the relevant clinical guidelines say. We then consider what did happen, and whether this fell short of the relevant guidance.
25. NICE guidance sets out the recommendations for managing care during and after surgery. It explains that clinicians should:
• offer different types of pain relief to manage postoperative pain (1.6.2) • consider prescribing pre-emptive pain relief for use when local anaesthesia wears off (1.6.4) • offer opioids when pain is expected to be moderate to severe (1.6.10) • offer PCA immediately after surgery for patients who cannot take oral opioids (1.6.11)
26. ERAS guidelines state:
• when patients rely on opioid alone for post-operative analgesia, this may cause nausea, sedation, and fatigue while increasing the risk of addiction… a multimodal post-operative analgesia pathway, with greater emphasis on non-opioid medications, preserves or improves patient experience and functional recovery after surgery. (section 10) • there are great discrepancies in patients’ responses to pain relief medications, including opioids (section 10).
27. The records from Miss O’s procedure show the Trust gave her spinal anaesthetic. Our anaesthetist adviser clarified that Miss O did not receive an epidural. They explained the anaesthetic was recorded as working well during the procedure, as Miss O’s heart rate and blood pressure were stable.
28. The records also show the Trust gave Miss O bilateral TAP blocks at the end of surgery. Our adviser explained that the purpose of these, along with the spinal anaesthetic, would have been to pre-emptively manage pain (in line with NICE guidance) and reduce the amount of opiates Miss O needed in recovery. This is in line with ERAS guidance, which recommends that clinicians should avoid reliance on opioids.
29. Pain charts from recovery show that Miss O had an initial pain score of 0 out of 3 at 12.55pm. Miss O disputes this, and explained she woke up in severe pain. An hour later, her pain score is recorded as 3 out of 3. The records show staff gave her morphine 3mgs (opioid pain-relieving medication) intravenously up to a total of 10mgs. Miss O was also given 150mcg of clonidine (medication to relax the blood vessels). Miss Os’ pain score is recorded as reducing to 1 out of 3 by 4pm.
30. There is no reference in the records to Miss O standing to try and reduce her pain. However, we have no reason to doubt her account that this happened. It is clear from her account, and the pain scores, that she experienced severe pain in recovery.
31. ERAS guidance explains that there are great discrepancies in patients’ responses to pain relief medications. Our adviser confirmed this; they explained that pain is subjective and pain relief requirements are very individual. They noted that Miss O did require more pain relief and was in severe pain, but this does not necessarily mean that the Trust failed to manage her pain.
32. Our adviser gave their view that staff gave Miss O various types of pain relief, and that she received appropriate doses of opiates. They also explained that there was not a clear case for giving Miss O access to PCA at this point. They explained that PCA is not a common choice in recovery, as hospitals prefer to use oral medication with less side effects.
33. We can see from the records that Miss O could tolerate oral pain relief, and that this did reduce her pain whilst in recovery. Considering this, and the advice received, we have found the Trust followed the relevant guidance in trying to manage Miss O’s pain whilst she was in recovery. There appeared to be no clear case for PCA, and the Trust ensured she had access to different types of pain relief.
34. Our decision is not intended to minimise the pain and distress Miss O did experience in recovery. It is clear she experienced significant pain after the operation.
Pain management on the ward, review by doctor
35. Miss O also complains the Trust failed to manage her pain after she was moved from recovery to a ward. She explained she continually buzzed for help as her pain was getting worse, and a family member who is a nurse had to ring staff to tell them Miss O needed more pain relief.
36. Miss O says that staff repeatedly called for a doctor to review her, but nobody attended for hours. She explained there was then a delay in her receiving PCA.
37. In responding to the complaint, the Trust apologised that Miss O’s pain was not effectively managed on the ward. It acknowledged staff tried to arrange a review by a doctor, but explained the doctor was unable to attend sooner due to seeing a patient in the Emergency Department.
38. As above, NICE guidance states that clinicians should offer different types of pain relief to manage postoperative pain (1.6.2).
39. The GMC’s ‘Good medical practice’ states that doctors must ‘promptly provide or arrange suitable advice, investigations, or treatment where necessary’ (15b). It also explains doctors must ‘take all possible steps to alleviate pain and distress…’ (16c) and ‘consult colleagues where appropriate’ (16d).
40. NMC guidance states that nurses must ‘maintain effective communication with colleagues’ (8.2) and ‘make a timely referral to another practitioner when any action, care or treatment is required’ (13.2).
41. Miss O’s records show Trust staff did not record pain scores between her transfer to the ward at 5.20pm and starting her on PCA at 11.40pm.
42. However, it is clear from Miss O’s account that she experienced significant pain during this period. She explained she was finding it difficult to cope and told nursing staff. This correlates with the clinical records (which show she was complaining of pain) and the Trust’s account (which acknowledges that staff repeatedly tried to call for a doctor to review her due to her high level of pain.)
43. We asked our anaesthetist adviser whether the Trust should have given Miss O access to PCA earlier than 11.40pm. They gave their view that as Miss O was noted to be in significant pain shortly after her transfer to the ward (at 5.20pm) and, as other measures had so far failed to control her pain, she should have been given access to PCA from this point. They explained the delay in doing so was a failure to act in line with NICE guidance (1.6.2).
44. Our gynaecology adviser also explained that a gynae doctor should have also been called to review Miss O at 5.20pm due to her unusually high levels of pain. They explained that severe and unusual levels of postoperative pain can indicate a post-operative complication such as internal bleeding and that there was a need to provide prompt investigations and treatment, in line with GMC guidance. This did not happen.
45. NMC guidance states that nurses must maintain effective communication and refer patients promptly, but the records show nurses did not call a doctor until 8.30pm.
46. They then took over an hour to attend due to an emergency in another department. Our gynaecology adviser explained the doctor should have undertaken basic checks such as reviewing Miss Os’ observations and urine output and carrying out a basic physical examination to make sure there was no internal bleeding.
47. There is no evidence this happened, but our gynaecology adviser clarified that Miss O did not have internal bleeding and there was therefore no clinical impact from this beyond a delay in calling an anaesthetist to provide further pain relief.
48. After the doctor’s review, there was then a delay of a further two hours before an anaesthetist saw Miss O and gave her access to PCA.
49. Considering the available evidence and advice received, we feel Trust staff failed to act in line with the above guidance in managing Miss O’s pain on the ward.
50. It is clear from the records that Miss O was in severe pain shortly after her transfer. She should have been reviewed sooner by a gynae doctor and given access to PCA shortly after she arrived on the ward. The Trust’s discharge summary and complaint response also acknowledges this delay in managing her pain.
51. We have gone on to consider what impact this delay had on Miss O.
Impact
52. Miss O explained that she continued to experience excruciating pain and discomfort after she was transferred to the ward. She explained she was in tears and repeatedly asking for help from staff. She also told us that it was not until she was given access to PCA that her pain started to reduce.
53. Miss O also explained her experience had a significant ongoing emotional impact on her. She explained how she has now been told she has PTSD as a result, how it has impacted her sleep, and how she has needed sleeping medication and counselling to help her recover. We are sorry to hear how much she has been impacted by what happened.
54. The records show that Miss O’s pain began to reduce shortly after the Trust gave her access to PCA. At 11.40am her pain score is reported as 3 out of 3. The next time she is checked at 1.55am, her pain has reduced to 0. It remained between 0 and 1 for the rest of her admission.
55. As above, Miss O should have had been reviewed shortly after her transfer to the ward, as her pain levels were unusually high. Our gynaecology adviser explained that had this happened, it is likely a doctor would have called for the anaesthetist sooner, and our anaesthetist adviser explained she should have then been given access to PCA.
56. Had Miss O been given access to PCA shortly after 5.20pm, it is likely her pain would have reduced much sooner. When she was finally given access at 11.40pm, Miss O reported she was able to reduce her pain. The PCA chart in her records show her pain had reduced to zero by 1.55am.
57. We therefore find that Miss O experienced significant avoidable pain between 5.20pm and 11.40pm, a period of approximately six hours. Aside from being in serious pain, we recognise this would have been very distressing and difficult for her.
58. We have carefully considered whether this has also had an ongoing impact on Miss O. We have considered her account, her GP records, the evidence from her counselling sessions, and the view of our psychiatry adviser.
59. We can see from Miss O’s account and the clinical records that the experience continued to affect after she was discharged. A different Trust referred her for therapy in August 2023, as she had reported ‘a lack of sleep…following the hysterectomy which she states was a very traumatic experience.’ The consultant recorded Miss O ‘was wondering whether she had post-traumatic stress disorder.
60. Her GP records from October 2023 also show Miss O reported having flashbacks and ruminating about what happened. Notes from her counselling sessions, which began in December 2023, also detail ‘ongoing sleep issues, rumination, trauma relating to a surgical procedure and aftercare that did not go to plan’.
61. Miss O’s counsellor wrote a statement which detailed that Miss O became dependant on zopiclone after the surgery, and that the lack of pain relief had a ‘significant psychological impact’, ‘unlocking older, unprocessed traumatic material she had previously managed to contain.’
62. The GP records from after the surgery detail Miss O using zopiclone and struggling with her sleep. For example, in early December 2021 she requested a sleeping tablet (although she did not attribute her difficulty sleeping to the admission). Miss O continued to experience ongoing difficulties with her sleep and records from early 2025 show her still trying to reduce her use of zopiclone.
63. From this evidence, we can see Miss O’s experience after surgery had an ongoing impact on her sleep and wellbeing.
64. Other evidence we have seen suggests that this was not the only factor in her experiencing these issues. Miss O’s GP records show she had long-standing issues with sleep. For example, information from before her surgery detail her ‘suffering from stress and insomnia’, which was attributed to life events and relationships. She was also diagnosed with ‘generalised anxiety disorder in 2017.
65. Her GP recorded that ‘she has tried so many different sleep hygiene measures’ and that they would be grateful for a referral for therapy. Miss O’s GP regularly prescribed her sleeping medication from throughout 2021.
66. Miss O continued to experience issues with her sleep in the months before her hysterectomy (attributed to personal issues and the menopause). In May 2021 the GP records show she was ‘not sleeping well’ and ‘requesting sleeping tablets’. In September, they detail her ‘struggling to sleep due to all that’s going on’.
67. Following the hysterectomy, it also appears that Miss O did not attribute the symptoms she was experiencing to her experience at the Trust until nearly two years after she was discharged. Between November 2021 and August 2023, she continued to request sleeping medication, but the records do not show her explaining that this was due to what happened after the surgery. For example, in March 2023 she attributes her difficulty sleeping to the menopause.
68. Our psychiatry adviser gave their view that there is a lack of clear evidence to show Miss O was suffering with the core symptoms of PTSD, or that she had been diagnosed with the condition using a diagnostic tool. They explained Miss O’s anxiety disorder and her unprocessed trauma from before her surgery (referred to in her counselling notes) means it is difficult to attribute her psychological symptoms solely to what happened at the Trust.
69. Our adviser also gave their view that Miss O’s insomnia was not solely linked the lack of pain relief after the hysterectomy. They explained that insomnia is a typical symptom of generalised anxiety disorder and is also a known symptom of the menopause.
70. Considering the above evidence and advice received, our view is that we cannot fully attribute the Trust’s approximately six-hour delay in giving Miss O proper pain relief to the ongoing emotional impact she told us about. We can see Miss O had longstanding issues with sleep that could be linked to other medical issues and factors.
71. It is also important to note that we have not found failings in the way the Trust managed Miss O’s pain in recovery. Miss O clearly experienced significant pain in the hours immediately after but we have found the Trust tried to manage it appropriately. This pain will have contributed to her overall experience and will be a factor in the long-term impact she told us about, but we cannot say the Trust was responsible for this. We can only consider the impact of the period where it delayed in managing her pain.
72. Our decision is not intended to minimise the pain Miss O experienced at the time, or the distress she experienced afterwards. It is clear from her account that it was a traumatic experience and that it continued to be a factor in her ongoing worry and distress.
73. We have gone on to consider whether we should recommend actions for the Trust to put this right.
Recommendations
74. In considering our recommendations, we have referred to the ‘NHS complaint standards’. The Complaint Standards support organisations to provide a quicker, simpler and more streamlined complaint handling service.
75. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.
76. Our Principles for Remedy are reflected in the NHS Complaints Standards UK Central Government Complaint Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services
77. To remedy her complaint, Miss O is seeking acknowledgement from the Trust that it did not manage her pain appropriately and for it to change its policy on pain management. She would also like financial remedy in recognition of the impact on her.
78. In its complaint response, the Trust acknowledged and apologised that the prescribed pain relief did not control Miss O’s pain. However, it did not explicitly acknowledge the delay in a doctor reviewing her and the delay in giving her access to PCA. It also did not acknowledge the impact of her being left in significant pain for over six hours. With this in mind, we recommend the Trust write to Miss O to acknowledge this within 30 days of the date of this report.
79. In its response, the Trust also informed Miss O of some improvements it has made to pain management since her complaint. It explained that staff now only transfer patients to a ward if their pain is properly controlled, and that this prevents delays in the prescribing of further pain relief.
80. It also sent details of an action plan to improve its service, which included steps to empower ward nursing staff to directly contact the anaesthesia team directly to arrange further pain relief. Our gynaecology adviser felt this was sensible step to reduce the impact of any future delays in doctor review on pain relief. Other actions included reminding gynaecology doctors to alert anaesthetists when they are unable to attend to patient who requires pain relief.
81. The Trust has also delivered training to nurses on the wards to remind staff to remind them about the importance of effective pain management. It explained it has also created a mandatory online learning pack on the topic.
82. We are satisfied that these steps will help prevent the failings we found from reoccurring and hope Miss O will also find these reassuring. We recommend the Trust write to her with full details of the actions it has taken (including its action plan) within 30 days of the date of this report.
83. To decide on a level of financial remedy, we review previous cases where the person has experienced similar injustice, along with our ‘Severity of injustice scale’. Our scale sets out the different amounts we might recommend depending on how significantly someone has been affected.
84. Level 3 of our scale includes cases where someone experienced a high impact injustice (such as trauma or severe pain) for a short period of time (up to a month), or cases where someone experienced a moderate impact injustice (such as distress) for a significant period of time.
85. We feel the impact on Miss O fits within this level. She experienced severe avoidable pain for around six hours, and her experience caused her a level of ongoing distress. As set out above, we have been unable to link this to the full impact she told us about.
86. With this in mind, we have recommended the Trust pay Miss O £1,200 in line with level 3 of our scale. We recommend it do this within 60 days of the date of this report.
87. We are sorry to hear of how significantly Miss O has been impacted by what happened during her admission and with the difficulties she faced in the years after the procedure. We hope our report gives her some reassurance about the steps the Trust has taken to prevent similar failings from reoccurring.