Recurring concern
Failure to provide timely and adequate pain relief
- Reports that mention this concern
- 19
- Times this concern has been raised
- 23
- Stated actions linked to this concern
- 28
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 19 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- the Shrewsbury and Telford Hospital NHS Trust
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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the Shrewsbury and Telford Hospital NHS Trust
There is no pharmaceutical requirement for Oramorph to be double-checked.
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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.
Linked response
- East of England Ambulance Service NHS Trust
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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East of England Ambulance Service NHS Trust
Entonox is not indicated for potential chest injuries; administering pain relief would require IV cannulation instead.
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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.
Linked response
- University Hospitals Sussex NHS Foundation Trust
Stated actions 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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University Hospitals Sussex NHS Foundation Trust
Revise the Trust Epidural Policy with clear guidance on disconnected and failed epidurals, including epidural failure.
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University Hospitals Sussex NHS Foundation Trust
Provide Acute Pain Study Day epidural-management training to Level 9A nurses and ensure shift-leading nurses are epidural trained.
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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.
Linked response
- NHS Greater Manchester Integrated Care Board
Stated actions 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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NHS Greater Manchester Integrated Care Board
Provide and document advice on non-pharmacological treatments when prescribing analgesia.
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NHS Greater Manchester Integrated Care Board
Share learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.
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NHS Greater Manchester Integrated Care Board
Consider running education sessions on non-pharmacological pain management and referral criteria for musculoskeletal services.
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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.
Linked response
- Cwm Taf Morgannwg University Local Health Board
Stated actions 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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Cwm Taf Morgannwg University Local Health Board
Develop a corrective Action Plan for Improvement addressing the concerns identified in the Regulation 28 report.
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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.
Linked response
- Care Quality Commission
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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Care Quality Commission
Care staff cannot administer non-prescribed pain relief because the home is not a nursing home and staff lack necessary clinical skills.
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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.
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.
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026