Catheter insertion on 16 April
15. Mrs H told us the catheter was too big and the catheter balloon burst. In her complaint to the Trust, she said she had been at catheter insertions before. She says she had never seen the amount of bleeding Mr H experienced on 16 April. She believes this means staff did not catheterise him properly.
16. The Trust said staff managed Mr H’s blood clots in the normal way by replacing his existing catheter with a three-way catheter.
17. Staff use three-way catheters to perform bladder irrigation. In addition to the channels used to inflate the catheter balloon and drain urine, the third channel allows staff to provide irrigation fluid.
18. The Trust added that the most likely cause of Mr H’s bleeding was that he unintentionally pulled the catheter out.
19. Mr H’s medical records show that staff inserted an 18 Fr three-way catheter with a straight tip to manage the blood and blood clots in his urine. Fr refers to French Gauge. This is the unit clinicians use to measure the diameter of different sizes of catheters.
20. We consider staff properly inserted the catheter. The fourth quality statement (on urinary catheters) in NICE Quality Standard 61 says when inserting catheters, staff should:
• clean the meatus (the opening of the urethra) before inserting the catheter • use an appropriate lubricant to insert the catheter.
21. Our clinical adviser reviewed Mr H’s records and these note staff inserting the catheter using the right steps including using instillagel as a lubricant, which is a type of gel.
22. Section 5.1.3 of the Catheterisation Guidance says staff can use a three-way catheter to facilitate bladder irrigation to clear blood clots.
23. Regarding catheter size, the Catheterisation Guidance says staff can use a range of sizes from 10 to 24 Fr. Staff can use an 18 Fr catheter when they are trying to manage blood clots. The guidance also says staff should inflate the catheter balloon according to the manufacturer’s instructions.
24. Our clinical adviser said the type and size of catheter and the balloon staff used was in line with the Catheterisation Guidance.
25. Having considered the evidence, advice and guidelines, we consider staff properly inserted an appropriate type and size of catheter for Mr H.
26. Unfortunately, we saw this catheter came out later in the day and caused Mr H’s bleeding. We are sorry to hear how distressing this was for him and Mrs H.
Discharge from hospital on 20 April
27. When Mrs H complained to the Trust about Mr H’s discharge from hospital, she said he was unwell. She said he was not mobile and he fell when he tried to get out of the car when he got home. She added his catheter got blocked again three days later and he needed to go back to hospital. She feels all this shows the Trust should not have discharged him.
28. The Trust said it assessed Mr H appropriately on 20 April and he was medically fit to go home.
29. We consider staff acted in line with Good Medical Practice and appropriately assessed that Mr H was fit to go home. Section 15 of Good Medical Practice says when assessing patients staff need to:
• ‘adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations, or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs’.
30. Staff assessed Mr H during the morning of 20 April. They noted the condition he came to hospital with on 15 April had resolved. Staff noted they managed these problems through bladder washouts and irrigation using the catheters they inserted. He had not needed further bladder irrigation since 19 April.
31. When staff examined him during the morning ward round, his catheter was draining well and he was drinking fluids. Rather than his urine being red, his catheter bag showed some pink urine. Staff noted observations like his blood pressure and temperature, which were normal. Mr H also told staff he was feeling well.
32. Staff noted he already had an appointment with oncologists scheduled later in the week for ongoing management of his cancer. We saw the Trust’s oncologists had been coordinating Mr H’s cancer treatment for several years.
33. The above shows that staff used the medical evidence available to do an appropriate assessment in line with Good Medical Practice.
34. Our clinical adviser said the evidence supported the Trust’s decision to discharge Mr H. Mr H’s acute condition had resolved and he was well enough to go home. He already had a suitable appointment scheduled to manage his cancer moving forward.
35. We recognise Mrs H’s family had a difficult experience when Mr H came home, and we are sorry to hear how distressing this was for them. We hope we have clearly explained our decision on this matter.
Discussion about palliative care and terminal diagnosis
36. The Trust said the oncology registrar, who saw Mr H to discuss the results of tests into the spread of his cancer on 28 April, asked him if he wanted them to contact Mrs H about this. Mr H asked the registrar not to do this at the time.
37. The Trust added that the registrar who saw Mr H on 30 April offered to contact his family. But Mr H declined this offer and said he would rather share information with his family about his cancer diagnosis. The Trust said it needed to respect his wishes, and it considered staff acted appropriately by not contacting Mr H’s family about these matters.
38. We consider the Trust acted in line with Good Medical Practice. Section 32 says doctors must give patients the information they want or need to know about their condition or care. When communicating about this, section 31 says doctors must listen to patients and take account of their views. Section 50 says doctors must treat information about their patients as confidential.
39. Mr H’s records for his review with the oncology registrar on 28 April show the registrar asked if he wanted his family to know about the outcome and if he wanted his family involved in planning supportive care to manage his cancer. Mr H declined this offer and said he would leave telling his family for the time being, so the registrar only shared this information with Mr H.
40. The records for Mr H’s consultation on 30 April show he told staff he did not want them to tell his family about the progression of his cancer. He said he would like to speak to his family about this. Because of this, staff did not share this information with his family.
41. On both occasions, staff acted in line with Good Medical Practice by listening to what Mr H said and respecting his wish for information to be kept confidential and not shared with family members.
42. We recognise Mrs H told us that staff knew who she was, and she expected to receive information on these matters from them. We are sorry to hear how distressing it was when Mr H shared this difficult news with her.
43. We hope we have clearly explained the relevant standards and why we have decided staff acted in line with them.