14. Mrs G complained about how the community nurses managed her husband’s catheter on 30 September and 1 October 2020. She said her husband’s bladder was full for almost two days. She told us his final hours were ‘harrowing’ and he should not have died in that way. She said her husband’s trauma, associated with the catheter, had a significant bearing on his death. We realise this was a very difficult time for Mrs G.
15. The relevant guidance we have considered is the RCN Guidance. Although this guidance came into effect later, this describes what was considered good practice at the time of the events complained about.
16. The RCN Guidance states when a patient is at the end of their life ‘if a full distended bladder or urinary retention is suspected, then prompt action of urethral catheterisation is needed before the patient becomes agitated or distressed.’
17. Therefore, as Mr F had not passed urine and was in pain, the hospice team called the community nursing service to assess Mr F for a catheter. The hospice team nursing care complements the care provided by other services and is not a replacement for it.
Catheter management on 30 September 2020
18. Mrs G said she understood the catheter should start emptying the bladder straightaway but this did not happen. We appreciate this must have been worrying for Mrs G.
19. The amount of urine that can be retained will vary from person to person, based on their anatomy and health. The average capacity of the bladder is 300mls - 600mls. Our adviser said a person can usually hold about 300mls of urine without pain.
20. When the bladder is full, you urinate, and the waste leaves your body. However, if you have urinary retention, your bladder does not completely empty when you urinate. This can happen to both men and women and it can be caused by various things, including blockages, medications or nerve issues.
21. The RCN Guidance states healthcare professionals must ‘ensure that catheterisation is based on a balanced decision with more benefits than disadvantages and in consultation with the patient, where possible’.
22. The community nurse who attended Mr F recorded his abdomen was swollen. It was ‘very distended and he was showing signs of pain’. The community nurse carried out a pre-void bladder scan. A portable bladder ultrasound device uses ultrasound to check how much urine is in the bladder. This was in line with the RCN Guidance that says ‘wherever possible a bladder scanner is the preferred option to measure residual urine volumes’.
23. This scan showed Mr F was retaining 609mls of urine in his bladder. This is a large amount. Our adviser said the decision to catheterise him was clinically appropriate and was in line with the RCN Guidance.
24. The RCN Guidance states what a nurse should consider, and what they should document, when a catheter is used. This information includes: the reason for the catheterisation, if the patient is in pain, whether a record of fluid balance (intake and output of fluid) is necessary, if the insertion was difficult, and the urine drained (and a description). It also states if no urine is drained the healthcare professional should record what action was taken.
25. The community nurse recorded there had been ‘some resistance’ when inserting the catheter, but documented that the catheter went in. After the catheter was put in place, Mr F passed urine.
26. The volumes documented in the community nursing records are contradictory. The community nurse recorded a voiding measurement of 374mls but also recorded he had passed 210mls. In a telephone note of a call with the hospice team that afternoon the nurse referred to the catheter draining 280mls of ‘clear urine with slight blood staining’.
27. Our adviser said the notes about the urine amounts are conflicting but from what was recorded the catheter does not appear to have been draining appropriately.
28. The NMC Code sets out the professional standards that nurses, midwives and nursing associates must uphold to be registered to practise in the UK. This states a nurse should:
‘13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care
13.2 make a timely referral to another practitioner when any action, care or treatment is required’
29. The community nurse recorded there might be a chance a small blood clot could form and block the catheter. She suggested Mrs G should encourage her husband to drink more fluids, as he had not been drinking a lot during the day. Our adviser said at this point a fluid balance could have been used, in line with the RCN Guidance, to record how much fluid was going in, compared to how much was draining. The community nurse did not do this.
30. From what we have seen, although the catheter did not appear to be draining properly, the community nurse took no action at this point and left. Our adviser said this was not appropriate.
31. If the community nurse had identified the catheter was not draining properly, they could have given a bladder washout (to remove any clots, debris or mucus) or requested advice on whether to re-catheterise at that time, or considered if any other action was required.
32. There is no documentation about what action the community nurse took while the catheter was not draining or assessing the function of the urinary catheter. There is also no record that the community nurse followed this up or sought advice.
33. There is also no evidence the community nurse followed up with Mr F or his wife, an hour or so later, to check if the catheter was draining. Our adviser said this could have reduced the chance of Mr F going into urinary retention again.
34. In summary, the catheter management on 30 September 2020 was not in line with the RCN Guidance and the NMC Code. The decision to catheterise Mr F was clinically appropriate. The community nurse appears to have given the relevant contact information to Mrs G in case of any problems. However, the community nurse should have done more to ensure the catheter was draining correctly. Instead of doing this she left Mr F and Mrs G. This amounts to a failing.
Catheter management on 1 October 2020
35. Mrs G said after the catheter was fitted on 30 September 2020 nothing came out ‘all night and all morning’.
36. On the morning of 1 October 2020, Mrs G called the community nurses to say her husband’s catheter was not draining. It is recorded a visit was due that day and the visiting nurse would be made aware of the situation and address this.
37. The community nurse visited at 11am. Our adviser said this was a timely visit (an hour after the phone call from Mrs G). There is nothing to suggest an undue delay here.
38. A bladder scan showed Mr F was retaining 999mls of urine. This is a significant amount of urine. The community nurse removed the existing catheter and re-catheterised Mr F. This was appropriate and in line with the RCN Guidance. This says if there are any complications, including a catheter not draining, the health professional should consider ‘if the support system and drainage system need a check to ensure they are effective’.
39. The community nurse recorded ‘on removal no evidence of trauma’. There is no record of why the catheter was not draining, for example, whether there was a blockage or any blood. The RCN Guidance states when a catheter is blocked and the catheter is removed because of blockage the catheter should be looked at to identify the cause. There is no record that this happened here.
40. After replacing the catheter, the community nurse recorded it was draining. They drained the concentrated urine immediately but the ‘post void residual’ left in his bladder was 800mls. Our adviser said 800mls is a large amount in the bladder. However, again the community nurse then left.
41. Section 13.1 of the NMC Code states a nurse should ‘accurately identify, observe and assess’ signs of normal or worsening health in the person receiving care. Although the catheter appeared to be draining well, in view of the large amount of urine still in Mr F’s bladder, the community nurse should have stayed for a while to monitor the catheter. This did not happen. From what we have seen there is a failing here.
Impact
42. Mrs G said her husband’s bladder was full and he was ‘in agony’. She thinks this had a significant bearing on his death. She said if the community nurses had done what they should have done, her husband would have been more comfortable and she might have had a bit longer with him.
43. On 29 September 2020 a community nurse telephoned Mrs G to check how things were. The community nurse recorded Mrs G said she felt well supported and she was expecting a GP visit on 30 September 2020. It is not recorded that Mrs G said her husband was in pain or discomfort at that time. A community nurse face-to-face visit was also planned for 1 October 2020.
44. The information available on 29 September 2020 does not suggest Mr F was in pain at that time. However, we realise he may have started to feel discomfort later that day when it appears his urinary retention began.
45. On 30 September 2020 Mr F’s bladder was full and at that stage it was recorded he was in pain. After the catheter was changed the nurse recorded that Mr F was comfortable.
46. As stated earlier in this report, on the following day the nurses changed his catheter as it was not draining. When the community nurse left, although the catheter appears to have been draining it was recorded there was 800mls of urine remaining in his bladder. This is a large amount, even more than the previous day when it was recorded he was in pain. The community nurse recorded Mr F was ‘more comfortable’ after the procedure. However, this does not mean he was comfortable or without pain.
47. The average capacity of a male bladder is between 400mls and 600mls. Mrs G explained her husband became very uncomfortable after 3pm, in the hours before he died. We realise this was upsetting and worrying for her. Mrs G said her husband had not passed urine for 46 hours. However, we can reassure her the records show that some urine was drained off by the community nurses (but the amounts documented in the records are confusing).
48. Typically a person passes between 800mls and 2000mls of urine in 24 hours. This will depend on a number of factors, including the amount of fluid intake and the person’s state of health. The morning of 1 October 2020 Mr F had 999mls of urine in his bladder. Our adviser said it is more likely than not that the catheter had been blocked for most of the time since the catheter change on 30 September 2020. Our adviser said from the information available it is likely the catheter was blocked again at the time of Mr F’s death, as he had become so uncomfortable.
49. The Trust told us the coroner carried out a post mortem examination by non-invasive technique (CT post mortem). This investigation confirmed Mr F had an enlargement of his heart (cardiomegaly) caused by combined aortic and mitral valve disease. They said this condition is sufficient to cause sudden death of a cardiac nature which would fit with the history provided. The coroner considered Mr F’s death was due to natural causes, locally advanced cancer of the lung, together with the coronary artery disease. The coroner said there was no evidence of anatomical injury of the urinary tract associated with the blocked catheter.
50. There is nothing to suggest the catheter management contributed to Mr F’s death. The coroner has already identified his death was due to the natural progression of his existing significant medical conditions.
51. However, if the catheter management had been in line with the RCN Guidance then the pain and discomfort at the end of Mr F’s life would have been avoided.
52. The records show that when the community nurse visited on 1 October 2020 Mr F had had some breakfast and two cups of tea. Our adviser said this suggests he was not in severe discomfort at that time. Nevertheless, given the increasing urine retention over this period, Mr F would have become increasingly uncomfortable, in addition to his existing symptoms. This would be in line with Mrs G’s account of her husband’s final hours.
53. Our adviser said the key action that would have made a difference was if the community nurse had called later in the evening of 30 September 2020 to check if the catheter was draining. From what we have seen it is more likely than not that this follow-up call would have prevented the subsequent issues.
54. We found that Mr F’s increasing discomfort from 30 September 2020 was avoidable. We have seen nothing to suggest he was in pain throughout this period. However, if the community nurses had done more to check if his catheter was draining correctly, Mr F could have been more peaceful and comfortable in the days before he died.
55. In addition, it is clear that seeing how her husband died has been unnecessarily traumatic for Mrs G. She told us it was very upsetting to see him like that. She added if she had known he was going to die in a few hours she would have stayed by his side all the time. She said ‘things would have been so different’. We appreciate Mrs G has found it difficult to come to terms with the way her husband died and sadly it has been an ‘agonising time’ for her remembering this. We have seen nothing to suggest the community nurses knew Mr F was going to die imminently. Nevertheless, the way they managed his catheter contributed to Mrs G’s distress at an already challenging time for her. We found this upset was preventable.
56. The Trust has not acknowledged the catheter management should have been better and the impact of this on Mr F and his wife.
57. Therefore we have partly upheld the complaint and made recommendations for further work. At final report stage we partly uphold a complaint if there are failings but we believe the effect of those failings was not as serious as those set out in the complaint.