First reported 12 Sep 2014•Latest report 8 Jan 2026
Definition
What this concern includes
Includes failures of the pain-management process involving assessment of pain, provision or selection of analgesia, response to reported pain, reassessment, escalation, specialist input and continuity of pain relief before transfer or discharge.
Not included
Excludes medication-prescribing, dispensing or administration failures when pain management is not the material safety concern.
Excludes generic delays, documentation or staffing deficiencies unless they directly impair assessment or provision of pain relief.
Excludes failures concerning non-pain symptoms or hazards without a material pain-management component.
Excludes specialist pain-service access as a standalone concern where the report does not identify an unsafe failure to manage the patient’s pain.
Reports
19
Distinct published reports
Individual concerns
23
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
28
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England3
Care Quality Commission2
Department of Health and Social Care2
University Hospitals Sussex NHS Foundation Trust2
Barts Health NHS Trust1
Beech Dene Residential Care Home1
Betsi Cadwaladr University LHB1
Care First Class (UK) Limited1
Cwm Taf Morgannwg University Local Health Board1
Delamere Medical Practice1
East of England Ambulance Service NHS Trust1
East Sussex Healthcare NHS Trust1
Home Office1
Hull University Teaching Hospitals NHS Trust1
Leeds Teaching Hospitals NHS Trust1
NHS trust12
Healthcare site5
Executive non-departmental public body3
Ministerial department3
Health and social care service regulator2
Local health board2
Integrated care board1
Private limited company1
Residential care home1
Type not available1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
East Sussex
Concerns raised1
Poor management of pain
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Require admission liaison with carers and use “This Is Me” information to establish how patients express pain and what interventions work.
Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2026.
Action
Require structured at least-shiftly pain assessments for patients unable to self-report, incorporating learning-disability tools and carer or next-of-kin input.
Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2026.
Action
Escalate unresolved or carer-reported pain to same-shift senior nursing review and medical assessment, with documented care-plan adjustments and daily pain-checklist review.
Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2026.
Action
Provide specialist Learning Disability Nurse review within 48 hours of admission for patients with learning disabilities.
Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2026.
Action
Implement an expedited fractured-hip and long-bone pain pathway, including prompt orthopaedic review, appropriate analgesia or nerve block, and a completed transfer pain checklist.
Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2026.
Action
Circulate a Safety Pin to share pain-management learning and reinforce expectations across divisions.
Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Audit pain-assessment documentation and escalation monthly, review results through Divisional Governance, and continue ward-round teaching on pain tools and documentation.
Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Action
Jointly plan care with carers and families at admission, document and act on concerns about pain, deterioration, or unmet needs, and improve communication through Trust and Sussex-wide programmes.
Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Inner North London
Concerns raised1
Failure to provide robust symptom control in A&E
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Failure to consider or plan alternative pain management during opioid overdose treatment
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Share opioid reversal guidance through palliative-care educational events and hold collaborative opioid-learning events with the integrated care system.
Stated by the Princess Alexandra Hospital NHS TrustStatus at responseThe respondent said that this action was partly complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East Riding and Hull
Concerns raised1
Failure to accurately assess pain in people unable to communicate with words
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Disseminate Abbey Pain Assessment Tool guidance through posters, pocket guides, intranet resources, QR codes and targeted staff training.
Stated by NHS Humber Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 24 January 2025.
Action
Mandate the eLearning pain-assessment module for all registered nurses across the Trust.
Stated by NHS Humber Health PartnershipStated plannedThe respondent said that this action was planned when they made their response on 24 January 2025.
Action
Introduce a standalone electronic pain-assessment section supporting alternative tools, including the Abbey and Visual Pain Assessment Tools.
Stated by NHS Humber Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 24 January 2025.
Action
Continue auditing pain-assessment quality and analgesic provision, and plan conversion of the paper Abbey tool to an electronic version.
Stated by NHS Humber Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2025.
Action
Deliver Trust-wide simulation training on recognising deterioration, assessing patients and escalating concerns, including learning-disability scenarios.
Stated by NHS Humber Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Without direct clinical involvement or access to Trust records, NHS England cannot comment directly on David’s care.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Hull University Teaching Hospitals NHS Trust should respond to concerns about David’s care and treatment.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to provide pain relief and consider a care package at discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
No analgesia was considered necessary because neither the patient nor her daughter requested it at discharge and shoulder pain was not subsequently reported.
Stated by the Princess Alexandra Hospital NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
Position
A care package was not considered necessary because the assessment found that the patient did not meet the relevant threshold.
Stated by the Princess Alexandra Hospital NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
Teesside and Hartlepool
Concerns raised1
Failure to respond to reported pain with pain relief or medical escalation
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Mandate pain assessments at every set of physiological observations through the electronic observation system.
Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 January 2024.
Action
Incorporate objective pain assessment tools and visual alerts for patients reporting moderate-to-severe pain.
Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2024.
Action
Monitor compliance with timely pain assessments and reassessments on an ongoing basis.
Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2024.
Action
Implement the Call 4 Concern initiative, enabling patients and families to request Critical Care Outreach review.
Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 January 2024.
Inner North London
Concerns raised1
Inadequate pain relief provision
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Launch a nurse-in-charge dashboard incorporating live pain-review and quality-and-safety metrics.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Action
Undertake and report a pain-team service review to identify response-time gaps and improvement processes.
Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
UCLH disputes that pain relief was limited to paracetamol, citing morphine, intravenous paracetamol, patient preference and one-to-one care.
Stated by University College London Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North West Wales
Concerns raised1
Unavailability of rapid analgesics to paramedics for immediate pre-hospital pain relief
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire Eastern
Concerns raised1
Delays in providing pain relief
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to provide pain relief
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review, update and relaunch the pain-assessment tool for clinical staff.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.
Action
Audit whether the pain-assessment process is embedded in clinical practice.
Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
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Includes failures of the pain-management process involving assessment of pain, provision or selection of analgesia, response to reported pain, reassessment, escalation, specialist input and continuity of pain relief before transfer or discharge.
