North East Ambulance Service NHS Foundation Trust

5. Mrs I complains staff at County Durham and Darlington NHS Foundation Trust missed opportunities to lessen her mother’s pain and keep her comfortable. She considers delays in care contributed to her mother’s death.

6. She says seeing her mother in pain and not receiving the care she needed caused her distress.

7. In bringing the complaint to us, Mrs I would like the Trust to pay her a financial remedy.

8. Mrs A was in her eighties and had dementia. In December 2022 she had a fall at home, and her daughter called an ambulance. She arrived in the emergency department at 7.30pm.

9. At around 3.30am a doctor discussed administering a nerve block to provide pain relief with Mrs I. She did not think her mother would tolerate this and was worried about her trying to use her injured leg if she could not remember it was sore.  The doctor prescribed some extra morphine and agreed to re-explain the benefits and risks if Mrs A’s discomfort worsened.

10. Staff moved Mrs A off the ward at around 6.00am. A doctor reviewed her and noted she would not allow a full examination as she was in pain. At around 9.00am another doctor noted surgery was due to take place the next day and recommended a nerve block for pain.

11. Mrs A had surgery to repair her hip fracture two days later. A doctor noted discharge would likely have to be to a care home as she would not be able to mobilise at home.

12. Mrs A’s kidney function began to deteriorate the following morning. Her liver also began to deteriorate. A doctor noted she appeared to be approaching the end of her life and began palliative care during the afternoon.

13. A palliative care specialist reviewed Mrs A at around 10am the next day. They noted she was very unwell and receiving end of life care. Around two hours later Mrs A sadly died.

Pain management

17. Mrs I complains about the way staff assessed and managed her mother’s pain. She says they made her mother wait too long for a doctor review, missed opportunities to control her pain and did not pass on information about her mother before moving her to a ward.

18. Mrs A arrived in hospital at 7.30pm and ambulance staff handed her over to emergency department (ED) staff at 7.50pm.

19. NHS England guidance for emergency departments says emergency department (ED) staff should complete an initial clinical assessment within 15 minutes of the patient's arrival. This initial assessment should include identifying the patient’s immediate care needs which includes medication and diagnostics.

20. It was not possible for ED staff to complete an initial assessment within 15 minutes of Mrs A’s arrival as it took ambulance staff 20 minutes to hand her over. Our ED adviser said staff should have completed the initial assessment during the handover.

21. Clinical records show ED staff documented a brief summary of Mrs A’s fall and that her observations in the ambulance had been within normal range. Our adviser noted the summary does not include any form of triage, new observations or ordering of investigations. We consider it likely ED staff did not carry out an initial assessment at this time.

22. ED staff first assessed Mrs A at 9.46pm which was almost two hours outside of the timeframe NHS guidance recommends. We understand this was because December 2022 was a period of unprecedented national demand. There were significant waits across for both ambulances and handover to ED staff.

23. Our adviser explained the initial assessment was an opportunity for ED staff to review Mrs A’s pain score and give her pain relief. Despite this staff did not record her pain score. There is no indication staff discussed Mrs A's pain with her or her daughter. This means they did not do anything to establish whether she needed further pain relief. We consider this was a missed opportunity to assess and manage Mrs A's pain.

24. Mrs A then experienced around an eight hour wait for a doctor review. We know the ED was under extreme pressure with many patients waiting to be seen. Our adviser said ED staff correctly identified Mrs A should have received a doctor review within one hour of the initial assessment.

25. We recognise how distressing both Mrs I and Mrs A found waiting for this review. We do not know how many patients were waiting ahead of Mrs A to be seen nor do we know how many of those were more unwell. On balance, we consider it likely that earlier doctor review was not possible.

26. At 3.30am the following day a doctor examined Mrs A and noted recent X-rays showed she had a hip fracture. NICE guidance on hip fractures says clinicians should ensure pain relief is sufficient to allow movements necessary for investigations.

27. The guidance says clinicians should offer additional opioids if paracetamol does not provide sufficient preoperative pain relief. Then consider adding nerve blocks if paracetamol and opioids do not provide sufficient preoperative pain relief.

28. We can see the doctor discussed administering a nerve block with Mrs I who did not think her mother would tolerate this. She was worried Mrs A would try to use her injured leg if she could not remember it was sore. The doctor prescribed morphine (an opioid) and agreed to re-explain the benefits and risks if Mrs A’s discomfort worsened.

29. We are satisfied the doctor acted in line with NICE guidance in assessing and managing Mrs A’s pain.

30. Mrs A remained in the ED until around 6.00am when staff moved her to a ward bed. NICE guidance says staff should assess the person’s pain hourly until settled on the ward. This does not appear to have happened as there are no further entries about pain in the records between 3.30am and 6.00am.

31. Our adviser said staff should have assessed Mrs A’s pain during the above period as this would have allowed them to give her pain relief before moving her. The evidence shows staff did not assess Mrs A’s pain before transferring her from a trolley to a ward bed. This was not in line with NICE guidance and constitutes a further missed opportunity to manage Mrs A's pain.

32. Mrs I says staff caused her mother significant pain when transferring her from a trolley to a ward bed. She considers this was because ED staff did not pass on important information about her mother’s pain during the handover.

33. The evidence we have seen suggests ED staff did not assess Mrs A’s pain before the handover. The records do not show what information ED staff shared with ward staff. Our adviser said this is common as handovers are usually verbal.

34. On balance, we think it is likely ED staff shared all the information they had with ward staff. The evidence suggests staff did not properly assess Mrs A’s pain in the ED meaning they could not give ward staff a clear picture of how severe it was.

35. Our orthopaedic adviser reviewed the pain relief Mrs A received on the ward and had no concerns with this. We can see this was in line with the recommendations in NICE guidance on managing hip fractures.

36. Despite this, it appears nurses on the ward did not regularly monitor Mrs A’s pain. There is limited documentation about Mrs A’s pain in ward nursing records. Our adviser said regular pain monitoring was important in Mrs A’s case. She had cognitive impairment due to dementia and may not have been able to vocalise pain on her own.

37. Mrs I is concerned staff did not manage her mother’s pain properly. The evidence we have seen shows staff missed several opportunities to do this between Mrs A’s arrival at hospital and her operation two days later.

38. We recognise how distressing this was for Mrs I to witness, especially after a long wait for an ambulance before arriving at hospital. We have found a failing in this aspect of the complaint.

Palliative care

39. Mrs I also complains staff did not keep her mother comfortable. She is concerned about the time staff took to refer her to the palliative care team.

40. The relevant guidance for this aspect of the complaint is NICE guidance on palliative care. This says adults approaching the end of their life and those close to them should have access to a healthcare professional 24 hours a day, 7 days a week who can access the person’s records and make informed decisions about changes to care.

41. The guidance says clinicians should have regular discussions with the patient and their loved ones about changes in the patient’s health as well as their needs and preferences. Clinicians should repeat assessments of the patient’s needs and review their advance care plan at key transition points such as when treatment goals have changed.

42. Clinical records show clinicians decided to stop actively treating Mrs A and move her to palliative care at 4.30pm on the third day of her admission. The goal of palliative care is to manage unpleasant symptoms and keep the person comfortable. Our palliative care adviser said any staff can provide palliative care in terms of managing pain and keeping a person comfortable.

43. A doctor prescribed anticipatory medications at the same time they decided to move Mrs A to palliative care. These are medications doctors prescribe in advance to ensure they are available to manage potential, sudden or worsening end of life symptoms. Our adviser said this meant nurses could administer morphine and other medications if and when Mrs A needed these.

44. We can see Mrs A received morphine on ten occasions. This included in response to her becoming distressed at around 2.00am. Our adviser said it looked like nurses managed Mrs A’s pain, and they saw no missed opportunities to keep her comfortable.

45. Mrs I is concerned about how long it took staff to refer her mother to the palliative care team. Our adviser said staff should have sent the referral at the same time they decided to move Mrs A to palliative care. We can see they sent it the following day which was a delay of around 12 hours.

46. We do not consider the delay in referral affected Mrs A’s palliative care. The purpose of palliative care is to keep a person comfortable, and any staff can provide this. We can see staff provided Mrs A with anticipatory medications to keep her comfortable. Our adviser saw no concerns with the palliative care staff provided Mrs A.

47. We recognise how frustrating Mrs I found the delayed referral especially given the delays her mother had already experienced. The evidence shows staff provided Mrs A with palliative care in line with NICE guidance.

48. We do not consider the Trust missed any opportunities to keep her comfortable at the end of her life. For this reason, we find no failing in this part of the complaint.

Impact

49. We have found a failing in the way the Trust assessed and managed Mrs A’s pain during her admission.

50. Mrs I considers delays in care may have contributed to her mother’s death.

51. Our orthopaedic adviser reviewed the records and had no concerns with the care Mrs A received for her hip fracture. They said failings around pain management did not negatively impact Mrs A as she received surgery within 36 hours of admission as per NICE guidance.

52. Clinical records show the surgery was successful, but Mrs A deteriorated after this. Our adviser explained there is always a risk to life from fracture or surgery to an elderly person with Mrs A’s clinical history. They said sadly Mrs A would still have died had the failings not occurred. We recognise how upsetting this will be for Mrs I.

53. Mrs I says the Trust’s actions caused her mother pain. She says this was distressing to witness.

54. We consider staff missed multiple opportunities to assess and monitor Mrs A’s pain. Both our ED and our orthopaedic adviser said it is likely Mrs A experienced unmanaged pain which would have caused her distress.

55. We consider the failing we have found meant Mrs A experienced periods of avoidable pain during her admission. It is clear witnessing this caused Mrs I distress for around three days. We consider after this point Mrs I’s distress was understandably due to her mother’s sudden deterioration and death.

56. When we find a failing led to an impact we go onto consider what steps the organisation may have already taken to put things right. In considering this we look at our Principles for Remedy. We also use our Severity of Injustice scale.

57. Level one of our scale covers low impact injustice such as annoyance, frustration, worry or inconvenience, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact.  We will usually consider an apology to be an appropriate remedy for these cases.

58. In its response to the complaint, the Trust apologised it did not provide Mrs A with adequate pain relief during her admission. It said it has since increased nursing staff to support with the care of patients specifically around the management of pain and administration of medications. It also arranged further education for staff around pain relief.

59. We consider the failing had an emotional impact on Mrs I for around three days. This level of injustice falls on level one of our scale. Given the Trust has apologised and taken learning, in line with our Principles for Remedy, we consider it has done enough to put right the impact of the failing for Miss A. We do not need to take any further action.

60. We hope our findings help Mrs I to understand what happened, and they help assure her we carefully considered all the concerns she raised.

1. We have carefully considered Mrs I’s complaint about County Durham and Darlington NHS Foundation Trust (the Trust). We are sorry to hear about her mother’s death and the significant impact this loss had and continues to have for her.

2. We consider the Trust provided Mrs A with palliative care in line with relevant guidance. We have seen no evidence the Trust missed opportunities to keep her comfortable at the end of her life and we have found no failing in this aspect of the complaint.

3. We have found a failing in the way the Trust assessed Mrs A’s pain during the admission. The evidence suggests staff missed multiple opportunities to manage her pain across a three-day period. We recognise this caused Mrs I distress.

4. The Trust has apologised and taken learning from this. We consider the Trust has already done enough to put right the impact of the failings on Mrs I. For this reason, we do not uphold her complaint.