Inadequate pain management for man dying of cancer in hospital

What happened

Mr B had renal cancer. In summer 2013 he went into hospital with severe sepsis. He died three weeks later. During his time in hospital, the palliative care team saw him every day and he had a number of painkilling medications. However, he told his wife and family at visiting times that he was left in pain because his medication was given late on many occasions.

Mrs B complained that her husband did not receive adequate painkilling medication. She said she had been tortured by images of him pleading for pain relief, which she said made her depressed and unable to sleep.

Mrs B also complained about how the Trust dealt with her complaint. She said the responses she received were not substantial enough, given the seriousness of her complaint.

The Trust met Mrs B in winter 2013 to discuss her complaint.

What we found

There was some confusion about what Mrs B expected the Trust to do after the meeting, because no minutes were taken and we could not say what was agreed. Mrs B spent many months waiting for the Trust to write to her. It apologised for the confusion, which we felt was appropriate. We did not uphold this part of the complaint.

While Mr B received good care from the palliative care team, there was a lack of initial and on–going pain assessments by nursing staff on the ward. This meant that Mr B's pain control was poor on many occasions.

The cancer pain management guidelines state that pain assessments should show the location of the pain, how severe it is, what makes it worse and the effect the pain has on the patient. These guidelines also say that accurate assessment and reassessment of pain is essential to improve pain relief.

Staff did not carry out any pain assessments during Mr B's time in hospital. This meant that on far too many occasions, he was in pain and did not get medication for the pain soon enough. This failing was serious and resulted in unnecessary pain for Mr B, upset for his wife when she visited him in hospital and also ongoing distress for her after his death. The Trust had not acknowledged any failings in Mr B's pain management and we upheld the complaint.

Putting it right

The Trust apologised to Mrs B for the failings in her husband's pain management, and paid her £1,000, in recognition of how she suffered reliving the memories of her husband's pain.

It also sent her an action plan detailing what changes it will make to help prevent a similar thing happening to other patients in the future.