The Trust did not do the urine test before Mr E’s cystoscopy
13. The preparation section of the NHS website page ‘Cystoscopy – What happens’ explains patients may be asked to urinate into a container so the urine can be checked for an infection. It goes on to say the procedure may be delayed if a urine infection is found.
14. In line with this guidance, the Trust’s cystoscopy appointment letter to Mr E, dated 8 June 2020, states ‘please be aware that you will be required to do a urine test before the procedure so it is advised that you come to the clinic with a full bladder’. It also says: ‘please come before your appointed time so you will have time to do what is required before you see the doctor’.
15. Mr E’s cystoscopy appointment was scheduled for 11.15am on 6 August 2020, and he said he arrived early at around 10.50am. He says he waited over an hour for his cystoscopy procedure, sitting on a chair where a nurse had told him to wait. He says he was eventually called into the room for his procedure at around 12.30pm. While he was waiting, he was desperate to urinate as he was still holding his bladder for the urine test. He said he was so uncomfortable before the procedure he asked a nurse if he could go to the toilet. The nurse went to ask the doctor to check. The nurse returned saying Mr E could go to the toilet and he therefore emptied his bladder.
16. Mr E said he never had a urine test before his procedure and he felt things were rushed. At the time, because of the long wait, he thought either the doctor had forgotten about him or appointments were running behind schedule.
17. We reviewed Mr E’s medical records and could not find any record of a urine test / urine dipstick test or result from the date of his procedure. We therefore asked the Trust to provide a copy. The Trust responded on 31 May 2022, advising ‘the GP letter dated 11 August 2020 indicates that a dipstick urine test was performed as is routine practice prior to the procedure. The results showed the presence of blood and when the test is positive, as in Mr E’s case, a request is made for MSU (mid-stream urinalysis).’ A mid-stream urine sample means you do not collect the first or last part of urine that comes out.
18. The Trust also advised, as stated in the clinic letter following the cystoscopy, Mr E had not provided a urine sample as requested. It said because the dipstick test urinalysis showed the presence of blood ‘this would support why a mid-stream urine test was also requested to further check’. It could not, however, confirm when it asked Mr E for a sample, that is, before or after the procedure. We know from the NHS guidance and our adviser, this should have been done before the procedure to determine whether Mr E had an infection. Mr E said no member of staff at the Trust asked him for a urine sample before the procedure.
19. We asked the Trust again about the urine test as it had not provided any records showing the result. The records it had given us showing ‘blood trace’ and ‘blood++’ were dated 10 September and 1 October 2020, after Mr E’s cystoscopy procedure.
20. When we confirmed our investigation, we asked the Trust again if it could provide a copy of the results it had referred to, including details of the leukocytes (white blood cells) and nitrates (a compound of nitrogen and oxygen) results from the dipstick test. It provided a copy of the flexible cystoscopy data form which shows the handwritten ‘+blood’ under ‘urinalysis docket’ and is dated 6 August 2020. This was the date of Mr E’s cystoscopy procedure. There is no indication of the time on this record, so we do not know when any sample was taken and where this result came from.
21. Our adviser said this dipstick test result is incomplete and does not record leukocytes and nitrates relevant to determining an infection. Our adviser also said the purpose of doing a urine test before a cystoscopy procedure is to determine the presence or absence of nitrites and leukocytes which, if present, may indicate a urinary infection. The presence of blood at that stage was already known as it was the reason Mr E was referred to the Trust for the cystoscopy procedure.
22. In line with the NHS guidance, our adviser said recording a positive or negative result for leukocytes and nitrates would have enabled the doctor to know whether the test result indicated infection. This was important to determine whether to proceed with the cystoscopy or postpone it to allow any infection to be treated with antibiotics. Our adviser said MSU would still be required, but the procedure would not be carried out unless there was an urgent reason to do so. Our adviser also said the records do not indicate there was an urgent reason to go ahead with the procedure without checking for infection first. If there was, we would have expected the doctor to have documented the reason for this in Mr E’s records. There is no indication that was the case.
23. The information the Trust has given us is confusing and does not clarify the situation. It told us it is confident it did the dipstick test before Mr E’s procedure, but has not provided strong evidence of this. It also suggested the test showed blood in Mr E’s urine and that he needed an MSU, but has not explained why it did not get this sample from Mr E. The handwritten note on the flexible cystoscopy data form does not persuade us, on the balance of probabilities, the Trust carried out the urine dipstick test on the day of, and before, Mr E’s procedure. We have not seen any record of a complete result which persuades us the Trust appropriately determined whether Mr E had an infection before going ahead with the cystoscopy procedure.
24. Importantly, this is in keeping with Mr E’s account in which he strongly denied having a urine test on the day of his procedure and specifically noted how uncomfortable it was to hold his urine without being asked to provide a sample.
25. We have therefore identified a failing and we have considered the impact of this.
26. Mr E said he felt extremely uncomfortable holding his full bladder for the urine test, which he feels was unnecessary as the Trust did not do the test. If the Trust had done the test as it should, he would still have had to hold a full bladder before his appointment. We understand this can be very uncomfortable. When we weigh up the evidence, we cannot say Mr E was wrongly left in discomfort because of the Trust’s mistake.
27. He also said following the cystoscopy procedure, he could not urinate all weekend which caused him pain. When he did urinate, his urine had a strong odour and unusual consistency, and contained visible blood. We appreciate this was uncomfortable for Mr E and why he is reluctant to have another cystoscopy. His GP confirmed he had a urinary tract infection (UTI) and prescribed antibiotics, followed by stronger ones when the test results came back.
28. We understand from Mr E’s consent form for the procedure and from the BAUS leaflet that infection requiring antibiotics is a recognised risk following this procedure. We know this risk materialised for Mr E as he had a particularly bad UTI which required strong antibiotics. He said once he had completed his course of antibiotics he recovered.
29. Our adviser said if the dipstick test had indicated possible infection and the Trust had postponed the procedure to treat it, Mr E would have had less chance of developing a symptomatic UTI after the procedure. But what we do not know is whether a test would have shown these indications (leukocytes and/or nitrates) in his urine. We cannot say, on the balance of probabilities, it would.
30. We have found the Trust did not minimise Mr E’s risk of developing an infection after the procedure. He will unfortunately never know whether the procedure should have been postponed or whether he could have avoided the infection and subsequent discomfort and pain. We accept why the Trust’s actions make him reluctant to have another cystoscopy procedure.
31. So, we cannot say, on the balance of probabilities, Mr E would not have developed an infection if the Trust has done the urine dipstick test. But we can say the failing has caused him worry and concern for the future, and left him never knowing if the outcome could have been better.
What the Trust has done to put things right
32. In the Trust’s 22 October 2020 response letter to Mr E’s complaint, it apologised that he was left feeling his procedure had not been performed properly and had been rushed. It accepted that some patients develop infection following a cystoscopy and said it is possible this is what happened to Mr E. The doctor added his apologies for the difficulties Mr E had experienced.
33. In its response letters to our queries, the Trust said the records indicate the urine dipstick test was performed as this is routine practice prior to the procedure. It said the results showed the presence of blood and a request was made for MSU, but Mr E did not provide a sample. It said it would be very unlikely to carry out a cystoscopy without a urine sample.
34. The Trust also said it is very sorry for Mr E’s experience. It added patients are given advice on what to expect and how to manage possible painful urination and UTI after the cystoscopy. It apologised if Mr E was not given the leaflet containing this information when he attended. It said it is looking at this as a point of learning for the nursing team. The Trust is also looking at how it can make sure it provides consistent communications to all patients, including a leaflet they can read in their own time.
35. The Trust said it has sympathy with Mr E’s experience but could not agree this was caused by its own failing and would therefore not offer financial compensation. It therefore has not accepted any failing.
36. We do not think this is enough. The Trust has failed to accept it does not have clear evidence that it did the urine dipstick test on the day of, and before, Mr E’s procedure. So, it has not accepted the impact this had on Mr E nor taken steps to put things right for him. The Trust has not identified any specific service improvements to minimise infection, as outlined in the NHS guidance. Therefore, we think there is more it should do to put things right.