Recurring concern
Failure to provide timely and adequate pain relief
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Request correctionFirst reported 12 Sep 2014•Latest report 8 Jan 2026
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
- Individual concerns
- 23
- Date range
- 2014–2026
- Stated actions
- 28
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to check administration of Oramorph and account for symptom masking
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 concernsEach 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.1
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Position
There is no pharmaceutical requirement for Oramorph to be double-checked.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Concerns raised1
Failure to provide pain relief before ambulance transfer
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.1
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Position
Entonox is not indicated for potential chest injuries; administering pain relief would require IV cannulation instead.
Stated by East of England Ambulance Service NHS Trust
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Concerns raised1
Failure to check disconnected epidurals in response to increasing pain
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 concernsEach 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
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Action
Revise the Trust Epidural Policy with clear guidance on disconnected and failed epidurals, including epidural failure.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Provide Acute Pain Study Day epidural-management training to Level 9A nurses and ensure shift-leading nurses are epidural trained.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to explore alternatives to repeated painkiller prescribing for persistent back pain
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 concernsEach 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.3
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Action
Provide and document advice on non-pharmacological treatments when prescribing analgesia.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Share learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Consider running education sessions on non-pharmacological pain management and referral criteria for musculoskeletal services.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised1
Lack of updated and documented pain scores before discharge
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 concernsEach 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
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Action
Develop a corrective Action Plan for Improvement addressing the concerns identified in the Regulation 28 report.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised1
Failure to offer analgesia to residents reporting pain after a fall
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.1
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Position
Care staff cannot administer non-prescribed pain relief because the home is not a nursing home and staff lack necessary clinical skills.
Stated by Care Quality Commission
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Concerns raised3
Delays in providing pain relief after hospital arrival
Failure to provide analgesia at discharge
Failure to balance medication effects and pain control
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Failure to ensure relief of severe pain before discharge
Failure to record pain scores at A&E triage
Failure to systematically reassess pain after analgesia and before discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to ensure emergency clinicians know what pain relief has already been provided
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026