Case Study: How a Pain Assessment Expert Witness Evaluated Claims of Poor Pain Control Prior to Surgery

When documentation contradicts perception: evaluating pain claims in medico-legal reviews

In this case, a patient awaiting surgery alleged that their pain had been poorly managed throughout admission. However, a detailed review of pain scoring records and prescription data revealed a very different picture. Pain scores were consistently low, with most entries indicating no pain or minimal discomfort. Although the patient later reported periods of increased pain, nursing notes did not support claims of persistent unrelieved symptoms.

An Apex pain assessment expert witness was asked to re-examine the case, comparing patient pain scores with medication records. The expert concluded that, based on documentation, the patient's pain was effectively managed even if isolated spikes occurred. While gaps in the drug administration records limited total certainty, there was no clinical evidence of neglect or prolonged unmanaged pain.

What the pain assessment expert witness identified in nursing notes and pain charts

The expert reviewed the patient’s pain scores across several weeks, along with the available medication charts. Findings included:

• Pain was scored between 0 and 3 for the majority of admission

• A single pain score of 5 was documented shortly before surgery, but was followed by a return to zero

• Prescribed analgesia included Paracetamol, Codeine, and Diclofenac, though administration records were difficult to interpret due to digital formatting

• No consistent reports of uncontrolled pain were found in the daily nursing evaluations

• Staff responded to rising scores promptly, adjusting care accordingly

• Palliative medications were initiated later in the admission for separate clinical reasons

“Pain was recognised, scored, and on the evidence available managed appropriately. The notes do not support an account of persistent, untreated pain.” — Apex Pain Assessment Expert Witness

What a pain assessment expert witness expects in surgical pre-admission care

For patients awaiting surgery, a pain assessment expert would expect:

1. Pain scoring at least once per nursing shift, using a consistent tool

2. Prompt adjustment to analgesia if pain exceeds a score of 3

3. Clear documentation of both prescribed and administered medication

4. Escalation to medical staff if breakthrough pain is not controlled

5. Inclusion of pain management in pre-operative handover documentation

In this case, the scores rarely exceeded 1, and when they did, pain returned to 0 shortly after. Despite some difficulty interpreting digital prescribing entries, the expert found no indication of clinical negligence.

Allegation vs. evidence: why perception doesn’t always align with the record

The expert acknowledged that pain is subjective and it’s not uncommon for patients to feel their discomfort wasn’t taken seriously, especially during prolonged waits for surgery. However, in legal proceedings, what matters is what can be proven from contemporaneous records.

Here, documentation showed pain was recorded, medication was prescribed, and no persistent high scores were observed. In the absence of contradictory evidence, the expert was unable to support a claim of mismanaged pain.