Pain relief for Miss H
17. Staff saw Miss H in recovery following the C-section surgeons performed at 5.08pm. They noted Miss H was still drowsy but complaining of pain at her incision site. The doctor stated Miss H had recently received local anaesthetic to the skin and subcut tissue during her C-section and was on oral morphine. However, the plan at this stage was to make an acute pain team referral.
18. At 5:15pm Miss H continued to report pain. The anaesthetist was said to have been aware and advised the continued use of oral morphine. At 6:02pm staff gave Miss H 20mg of Oramorph (a brand name for morphine sulphate: a strong painkiller taken by mouth).
19. Miss H was next reviewed by a midwife at 10:30pm, in which ‘no concerns’ were noted by staff, and she was said to be ‘alert and comfortable’. Miss H took her next dose of Oramorph at 11:54pm. The midwife made a similar assessment at 12:30am on 31 May. They noted ‘client [Miss H] currently feeling well in herself, lying on her bed’.
20. At 9:00am Miss H’s care was taken over by new staff. These staff recorded, ‘introductions made, and history noted’. There was no mention of pain or medication at this time. At this stage, A was receiving care in the NICU and Miss H was seen by a midwife at 9.48am. Miss H reported ‘some abdominal pain and pain in her hip’ to the midwife. We note from her clinical records Miss H has Ehlers Danlos syndrome (EDS) and has a history of dislocations.
21. At 11am a bedside check was performed by one of the midwives. Miss H was still in the NICU. She returned at 1.20pm, informing the midwives she was in moderate pain. Staff provided Miss H with Oramorph and paracetamol. The midwife advised Miss H to come back to the postnatal ward for regular pain relief to avoid long intervals between medication. At this point, her last dose of morphine had been at 3.00am that morning.
22. The acute pain team reviewed Miss H at 3.49pm. She informed them pain was moderate at rest, severe when moving and was limiting her mobility. Miss H reported morphine immediate release 20mg was effective, reducing her pain to mild for approximately three hours. The pain team recommended Miss H assess pain frequently and administer pain relief when required. Staff noted Miss H was aware she could request 20mg of morphine every three hours and was happy with this pain relief plan. Her next doses were administered at 4.49pm and 8.05pm.
23. At 10.21pm Miss H complained about pain to the midwife. However, the midwife informed her she was not due for pain relief. As previously mentioned, her records show she took morphine orally at 8.05pm. Miss A took her next dose at 11.09pm, in keeping with the three hours required between each dose.
24. On 1 June at 8.40am Miss H was visited by a midwife taking over her care. The midwife introduced themselves. They made no note about pain at this time. At 9.40am Miss H had ‘oral analgesia for pain relief’. It is unclear from the records what pain relief Miss H received at this time, but we see at 1.39pm she received further morphine and similarly at 5.48pm.
25. On 2 June at 12.00am, 4.08am and 9.06am morphine was taken orally. At 1.19pm following a review of Miss H, a ward midwife stated ‘client appears well and comfortable. Her analgesia discussed and will still be on paracetamol and PRN [when needed] Oramorph for now’. Her next doses were provided at 4.30pm and 9.31pm.
26. On 3 June at 1.39am Oramorph was given and at 9.00am staff noted Miss H’s pain to be well controlled. Miss H expressed she had to wait ‘long periods for Oramorph’. The midwife apologised and explained how the ward had been very busy. It is not clear from the records at which points Miss H may have requested morphine, nor when the delays may have occurred on account of the busy ward.
27. At 1.30pm Miss H was seen by a doctor who reviewed her pain relief plan, documenting her usage of Oramorph since staff prescribed it. This was as follows: ‘31st May 100mg, 1st June 40mg, 2nd June 100mg and 3rd June 20mg (thus far)’.
28. Following a discussion with the acute pain team, the doctor talked to Miss H about differentiating her types of pain given she also had EDS. She was said to be aware morphine was for her acute pain, not chronic pain. The doctor acknowledged her plan was frequent pain assessments with use of as required pain relief, and the Trust proceeded with this, administering 20mg of morphine at 1.39pm, 10mg at 2.36pm and 20mg at 9.46pm.
29. On 4 June, Miss H received two 20mg doses of morphine at 5.42am and 1.35pm before self-discharging against medical advice at 4.58pm. We considered the pain relief staff gave Miss H from the point she woke up after her C-section until she left hospital.
30. Section 1.4.10 of NICE guideline 192 says staff should ‘provide pregnant women having a caesarean birth with information on the different types of post-caesarean birth analgesia, so that they can make an informed choice’.
31. We can see an anaesthetist documented in Miss H’s records a conversation about pain, analgesia and surgery related pain. Whilst it is not documented what exact pain relief options were mentioned; this does suggest staff discussed pain relief options and they acted in line with NICE Guideline 192.
32. In deciding on the type of pain relief medication, the Trust recognised on account of Miss H’s allergies to nonsteroidal anti-inflammatory drugs (NSAIDS) and codeine, these were not suitable for use. This meant not all pain relief options were available to Miss H, which our obstetrician adviser deemed to be an appropriate judgement.
33. Thus, in line with domain one: section seven in Good Medical Practice, the Trust adequately assessed Miss H’s condition and promptly provided suitable treatment in making an acute pain team referral.
34. In terms of the pain relief plan implemented by the pain team, our obstetrician considered oral morphine was suitable for Miss H.
35. We note the Trust’s Anaesthesia Policy refers to patient control analgesia (PCA). Section 1.6.16 of NICE Guideline 192 says PCA should be considered. The guidance says, ‘if intravenous PCA is not acceptable to the woman or person who has given birth, or the pain is less severe, consider oral morphine sulphate’.
36. We see from the records, conversations were had between the pain team and Miss H about pain relief options, but it is unclear whether PCA was discussed at this time. However, given that the Oramorph provided following the acute pain team referral left Miss H feeling ‘comfortable’ and ‘with no concerns’, we consider it was appropriate for the level of pain Miss H was experiencing. It is a medication NICE Guideline 192 says staff can use.
37. In terms of the frequency in which staff gave Miss H this medication, we see the approach taken follows the Trust’s local policy approach to oral morphine. The Trust’s Caesarean Section Policy says ‘Oramorph 10 – 20mg, PO, 2-3 hourly’ should be available to patients following their operation-section. We saw staff followed this regime, as they made morphine available to Miss H every three hours.
38. We do recognise Miss H raised concerns with the midwives she had to wait ‘long periods for Oramorph’. The records do show staff apologised for this, stating it was on account of the ‘busy ward’. It is not clear at which points Miss H may have requested morphine, nor when the delays may have occurred. However, we can see whenever Miss H reported pain, if she was in a position to receive pain relief (meaning at least three hours since her previous dose), the Trust did provide it.
39. One exception to this was on 31 May at 10:21pm, when the staff declined to provide Miss H with pain relief despite her requesting it. This decision was in line with policy and the acute pain team’s plan, given Miss H had already taken morphine within the last three hours.
40. On the whole, our obstetrician deemed Miss H’s pain relief management, and the frequency in which staff provided pain relief, to be appropriate. They did recognise at certain intervals Miss H went longer than three hours without Oramorph, but this was attributable to Miss H being in the NICU with A. We saw it is evident from her notes staff informed Miss H to return regularly to the postnatal for pain relief medication.
41. We understand how distressing Miss H’s experience must have been and do not criticise her for wanting to be with A whilst he was unwell. We understand Miss H being off the ward was a barrier in her receiving further pain relief and so we cannot be critical of the Trust for not administering Miss H’s pain relief while she was off the ward.
42. We can see when Miss H was on the ward her pain relief was managed in line with guidelines. As such, we can see no indications anything went wrong in relation to the management of Miss H’s pain relief and thus, will not be taking this complaint any further.
The Trust’s response to A’s health conditions
43. When Miss H gave birth to A, staff noticed some respiratory distress in A. They resuscitated him after delivery. The midwives provided oxygen to support him.
44. Staff admitted A to the NICU, and they noted he recovered quickly, maintaining stable cardiovascular function throughout this admission time.
45. The Trust took A’s bloods and started him on a course of antibiotics for a possible sepsis infection. Staff also recognised poor feeding in A and commenced intravenous (IV) fluids.
46. Whilst on the neonatal unit, the Trust provided phototherapy for A’s jaundice. This is a form of light therapy used to reduce bilirubin levels (yellow pigment) in newborns. His jaundice improved, but staff recognised it was something that needed monitoring once discharged.
47. On the neonatal unit, staff started A on mixed enteral feeds, and he was discharged to the postnatal ward on 1 June. The staff noted he was tolerating feeds well at this time. From the notes we see prior to this admission, Miss H is said to have reported that he was more sleepy and not feeding as well.
48. At this stage A’s blood markers were normal, and his blood culture was negative, therefore the Trust stopped his antibiotic treatment for sepsis.
49. Whilst on the postnatal ward, there is little documented about A’s condition. However, we do not criticise the Trust for this.
50. We see that on 1 June a record of A’s temperature was taken, he was said to be feeding well, with no parental concern at 10pm. There are further entries on 2 and 3 June recording A to be feeding well, with no parental concerns and further notes suggesting A was active, responsive and had good tone.
51. However, we do see from the notes at 12.10pm on 3 June Miss H reported A to be clammy and hot. She also highlighted she had been concerned for several days and felt this had not been escalated appropriately. We note that apologies were made.
52. Additionally, we do see that when A was re-admitted to the neonatal unit, following bilious vomiting on 3 June, Miss H reiterated that A had been quite lethargic and hot to touch. As A was not on formal observations prior to this point, no temperature had been recorded.
53. Once the paediatricians had transferred A back to the neonatal unit, they also stopped A’s feeds. A’s blood test was said to be normal, with a normal lactate.
54. In view of the bilious vomiting (green or yellow-green vomit), staff performed an abdominal X-ray, and A was referred to the paediatric surgical team. The Trust do not have paediatric surgery, so he was transferred to a unit at another organisation where this was available.
55. Our neonatal adviser went over the above documents and explained good practice for handling a newborn baby’s infection in a neonatal setting. They said NICE Guideline 195 should have informed the Trust’s response to this.
56. One of the key points in NICE Guideline 195 (1.1.2) is that if clinical concerns about possible neonatal infection arise at any point, staff should consider antibiotic treatment and not delay this treatment.
57. We see from the notes that when concerns first emerged about A having an infection, the Trust commenced 48 hours’ worth of antibiotics. This is in line with NICE Guideline 195.
58. NICE Guideline 195 sets out what is appropriate intrapartum antibiotics. It states for those without a penicillin allergy, the use of Benzylpenicillin is recommended, of which the Trust gave to A in this instance.
59. This guidance also sets out clinical indicators for neonatal infections, which includes respiratory distress, jaundice, vomiting, and feeding difficulties. These symptoms were all recognised by the Trust and treated during A’s first admission to the NICU.
60. We understand from Miss H, following A’s discharge from the NICU she reported some of these symptoms to the midwives. We appreciate how stressful this time must have been for her. We do see evidence from the notes that A’s symptoms were acknowledged and treated in line with guidance.
61. NICE Guideline 194 states that bilious vomit is a symptom and sign of unwell babies and can act as an important indicator of possible serious illness. The BAPM Guidance says following green vomit, staff should quickly examine a baby and perform an X-ray.
62. Therefore, in recognising the green vomit, then staff promptly arranging an X-ray for A, and a surgical review and transfer to a different site where surgery is available, the Trust followed this guidance. Our neonatal adviser confirmed they would expect to see such actions.
63. As such, considering this evidence and advice, we see no indications that something went wrong and will not be carrying this complaint forward to a detailed investigation.
64. We acknowledge how frightening and distressing this experience was for Miss H and her family, and we appreciate Miss H for taking the time to voice her concerns with us. We know this complaint means a great deal to Miss H, so we hope Miss H finds some reassurance in our review of the evidence available, how we reached our decision and our consideration of the Trust’s actions.