Recurring concern

Failure to investigate persistent or severe pain

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First reported 28 Jun 2018•Latest report 6 Mar 2023

Definition

What this concern includes

Includes failures to investigate persistent or severe pain when the pain or associated findings warrant further clinical enquiry, diagnostic testing, observation, referral or escalation, including persistent back pain and severe unexplained pain.

Not included

  • Excludes failures concerning investigation of non-pain symptoms or abnormal test results unless persistent or severe pain is also a material part of the asserted concern.
  • Excludes delays or omissions in treatment after the cause of pain has been adequately investigated.
  • Excludes generic clinical investigation, professional-curiosity or staffing deficiencies where no persistent or severe pain investigation failure is identified.
  • Excludes routine pain assessment or analgesia failures where the unsafe condition is not failure to investigate the cause of persistent or severe pain.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2018–2023

First to latest report issue date

Stated actions
1

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.

Audlem Medical Practice1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Royal Stoke University Hospital1

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.

  1. East London

    AI-generated summary

    Maureen Edna Dick · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Maureen Edna Dick was admitted to hospital with likely sepsis and was at high risk of developing a pressure ulcer. A pressure ulcer developed and deteriorated, with concerns including inadequate risk assessment, repositioning, assessment and investigation, and failure to diagnose osteomyelitis before transfer. She died at Broomfield Hospital from her infected hospital-acquired pressure ulcer; the inquest concluded that her death was contributed to by neglect.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of professional curiosity in investigating causes of severe pain

    Wider context from the report

    “1. There was a lack of professional curiosity by the medical staff in relation to investigating the cause of Mrs Dick’s severe pain in October 2021. ”

    Source location

    Maureen Edna Dick · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    John Robert Maltby Worthington · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Robert Maltby Worthington fell down stairs in late March or early April 2017 and was treated for a head injury, with back and neck pain noted. He was later found to have spinal and rib fractures and pneumonia, and died in hospital on 29 June 2017 from bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The concerns included not undertaking further imaging after the initial fall and not recording a full set of observations or conducting further investigations when he later saw his GP with persistent back pain.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to investigate persistent back pain and tenderness

    Wider context from the report

    “(2) Mr Worthington persistently complained of back pain. He saw his GP on the 13th April 2017. He was tender on his back. No further investigation was recommended and a full set of observations were not taken or recorded. He presented to the hospital 3 days later with irreversible bronchopneumonia. A full set of observations may have given an earlier indication of the developing problem. ”

    Source location

    John Robert Maltby Worthington · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider or make x-ray referrals for older patients after significant trauma.

    Verbatim wording from the response

    “When ████████ examined Dr Worthington she did not feel that an x-ray of the ribs/lumbar spine was indicated given that Dr Worthington was not suffering from any midline lumbar spine bony tenderness. In retrospect however, ████████ accepts that an x-ray may well have picked up the fractures sustained by Dr Worthington which in turn may have led to a different outcome. Having reflected on this aspect of the case, ████████ is now more likely to send patients of a similar age for x-rays in future after any significant trauma.”

    Source location

    2018-0204-Response-by-MDDUS
    Page 2 · response
    Published 14 August 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    An x-ray was not considered indicated at the time because there was no midline lumbar spine bony tenderness, although this assessment was later reconsidered.

    Verbatim wording from the response

    “When ████████ examined Dr Worthington she did not feel that an x-ray of the ribs/lumbar spine was indicated given that Dr Worthington was not suffering from any midline lumbar spine bony tenderness. In retrospect however, ████████ accepts that an x-ray may well have picked up the fractures sustained by Dr Worthington which in turn may have led to a different outcome. Having reflected on this aspect of the case, ████████ is now more likely to send patients of a similar age for x-rays in future after any significant trauma.”

    Source location

    2018-0204-Response-by-MDDUS
    Page 2 · response
    Published 14 August 2018

    Open published response
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Data last updated 7 September 2026