Decision Report 201304220

Summary

Mr C complained about poor pain management and lack of information following hernia repair surgery (a procedure to address a bulge or protrusion of an organ through the structure or muscle that usually contains it) at Gartnavel General Hospital. Mr C said that he suffered severe pain because he was not given patient-controlled analgesia (PCA) morphine following the surgery, despite the anaesthetist having discussed his pain management and agreeing to the PCA at Mr C's pre-operation assessment.

Mr C was taken back to theatre the following morning to find out the reasons for his worsening pain, but no complications were found, and his surgery was considered successful. He suffered breathing difficulties which resulted in him being transferred to the high dependency unit (HDU) and then to an intensive treatment unit in a different hospital where he recovered several weeks later. Mr C also said that the cause of his severe pain and respiratory failure was not fully explained to him.

In responding to the complaint, the board said the anaesthetist discussed with Mr C that he would be assessed after the operation to see if a PCA was necessary. However, they also said that the respiratory failure following surgery was precipitated by poor pain control and that earlier establishment of PCA might have altered the sequence of events, although they could not be certain of this. As a consequence, Mr C was advised that in the event of future surgery, PCA and HDU care would be arranged for him because he would have a high risk of respiratory failure again.

We took independent advice on this case from one of our medical advisers, after which we upheld the complaint. Our adviser said that it was reasonable for the anaesthetist to say that the PCA would be put in place after Mr C's operation, if it was needed. However, we were critical that the PCA had not been written up on Mr C's drug chart before he was transferred from the theatre to the ward, so that it would be available if necessary. This was especially important as the record of Mr C's surgery indicated that he had undergone a long and difficult procedure, and it was highly likely that strong analgesia would have been necessary later in the evening. We considered that it was likely that a PCA would have avoided the subsequent problems with his pain relief.

Recommendations

We recommended that the board:

• share our findings with relevant medical staff involved in Mr C's pain management at the hospital in order to ensure lessons are learned;
• apologise to Mr C for the failings our investigation identified; and
• ensure that the medical staff involved in Mr C's care at the hospital record information discussed with patients and their families in line with General Medical Council guidance.