SPSO (Scottish Public Services Ombudsman) decision

Lanarkshire NHS Board

Decided 1 August 2021 Reference 201909937 Outcome: Upheld Sector: Health Category: Clinical treatment / diagnosis Body on this site: NHS Lanarkshire

Themes assigned by this site (AI-generated): Clinical negligence harms learning, Inaccurate and inaccessible patient records

Full decision

Decision (the SPSO's words)

Summary

C complained that they were provided with inadequate pain relief following surgery. C has chronic pain and as such required more careful management of pain relief due to their high tolerance of opioids. The board considered that they had appropriately assessed and managed C's pain.

We took independent advice from a consultant anaesthetist. We found that while the postoperative pain relief provided was appropriate, there was a lack of true multi-modal analgesia (pain management which combines various groups of medications for pain relief) intra-operatively (during surgery) which increased the chances of immediate pain control problems. We upheld the complaint and made recommendations for learning and improvement.

Recommendations

What we said should change to put things right in future: The board should reflect and specifically consider our suggestion for further learning and advise this office of what further improvements they intend making.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Related reading

View Decision Report 201909937 as a PDF (25.28 KB) Updated: August 18, 2021

From: SPSO (Scottish Public Services Ombudsman), decision 201909937, 1 August 2021