5. Mr U complains the Trust did not arrange to remove his catheter, inserted on 20 May 2021, in a timely manner.
6. He says he was in a lot of pain until and after, the removal of the catheter and had been suffering with urinary incontinence with leakages of blood and urine. This was extremely distressing for Mr U.
7. Mr U would like an acknowledgement of failings and an apology. Mr U would also like service improvements.
8. In 2019, Mr U was diagnosed with prostate cancer. He received radiation therapy treatment from 2019 to 2020 and is currently in remission. Because of the radiation treatment, he has had a range of urinary and bladder problems. The Trust received a referral for Mr U to check for bladder cancer.
9. Mr U had a rigid cystoscopy and urethral dilation at the Trust on 20 May 2021. A rigid cystoscopy is a procedure to examine the inside of the bladder, as well as to take biopsies from the bladder if needed. Urethral dilation is where the urethra or the meatus (external opening) is stretched back to its normal width. The Trust inserted a catheter.
10. Due to the pain Mr U was experiencing, he could not wait for his TWOC appointment in June. He attended A&E on 24 May to have his catheter removed.
15. In its complaint response, the Trust explained that ideally the catheter would be removed 72 hours after the operation. It says this is the recommended time for a TWOC after urethral stricture treatment. But, in Mr U’s case, it says it could not remove his catheter within this timescale because there were no weekend TWOC services (the 72 hours fell on a Sunday).
16. The BAUS guidance for treatment of a urethral stricture says that if a patient has had a, ‘catheter put in afterwards, we normally remove this is in outpatient’s one to ten days later’.
17. Section 15b of the GMC guidance says that doctors ‘must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must promptly or arrange suitable advice, investigations or treatments where necessary’.
18. Mr U had a rigid cystoscopy and urethral dilation on 20 May 2021 and the Trust says it explained to him that it planned to remove the catheter on 24 May.
19. Mr U called on 21 May to ask whether the Trust had made him an appointment to remove the catheter. The Trust said the clinic on 24 May was full, but the nurse on duty on 22 May was asked to contact Mr U on that day. Unfortunately, the same nurse was also running a complex clinic on that day, so they could not contact any more patients on that day. The Trust says this is why it did not contact Mr U over the weekend. Mr U was not aware of this at the time.
20. Mr U called again on 24 May and the Trust told him the clinic that day did not have capacity to see him. The Trust booked Mr U’s appointment for 14 June, which was the next available appointment. Mr U attended A&E to have his catheter removed on 24 May due to the pain, side-effects and distress it was causing him.
21. In the clinical notes of the operation on 20 May, the post-operative plan was for Mr U to return to the clinic the week after for a TWOC. It also says ‘requested Monday 24/5/21’ which, based on the Trust’s complaint response, means it planned to remove the catheter on 24 May. Mr U did not get any communication from the Trust to confirm this appointment.
22. While the planned timeline of providing a TWOC was in line with the BAUS guidance, and so was the intention to remove the catheter quickly, this did not happen. Our adviser says the Trust should have confirmed an appointment for catheter removal at the time of discharge. Or, the Trust should have contacted Mr U before the planned removal on 24 May. This would have prevented Mr U having to attend A&E due to the lack of clinic availability.
23. Overall, the Trust’s actions here were not in line with the GMC guidance. The Trust did not arrange the TWOC for when it said it was going to happen. This was a failing.
24. Mr U says he was in a lot of pain until and after the removal of the catheter and had been suffering with urinary incontinence with leakages of blood and urine. This was extremely distressing to Mr U. Although we are looking at the removal of catheter, it is important to note the overall side effects of the procedure Mr U went through. This is so we can decide whether the impact caused was a result of the Trust’s actions or not.
25. The BAUS guidance also gives information on the risks and after-effects of rigid cystoscopies and urethral stricture procedures.
26. Some of the common risks or after-effects of a rigid cystoscopy include:
• mild burning on passing urine for a short period of time after the procedure • bleeding for a few days after the procedure.
27. Similarly, some of the risks or after-effects of a urethral dilation include:
• mild burning or bleeding for a short time after the procedure when passing urine • urinary tract infection requiring treatment with antibiotics • decrease in the quality of erections requiring treatment.
28. It also explains that if ‘you develop a fever, frequent passage of urine, severe pain on passing urine, inability to pass urine or worsening bleeding, you should contact your GP immediately’.
29. Our adviser has reviewed the medical records for both procedures and has not seen any signs that the Trust did them incorrectly. They have not raised any concerns about how the procedures went ahead.
30. Mr U was put under general anaesthetic. The Trust gave antibiotics (gentamicin and amoxicillin) and it inserted a catheter. This can happen after either of these procedures and is in line with the BAUS guidance. Our adviser is aware of these side effects Mr U experienced as they are well known, especially if the patient has a history of prostate cancer. They do not suggest that anything has gone wrong.
31. Our adviser says that either the biopsy or the catheter could have caused the pain, discomfort and bleeding he had. They go on to say that incontinence while the catheter was in is likely to be due to catheter related bypassing (when the bladder muscles twitch and squeeze without you controlling them - a type of spasm). Prostate Cancer UK says this can be more likely in patients who have had radiotherapy. Radiotherapy can irritate the lining of the bladder and urethra.
32. We recognise the pain Mr U describes must have been distressing on its own, even without the side-effects he experienced.
33. The Trust has accepted that it did not arrange to remove Mr U’s catheter in a timely way on 24 May, as agreed on the day of his discharge. It apologised to Mr U for this and that he had experienced significant pain until it removed the catheter in A&E.
34. Our ‘Principles for Remedy’ say that, ‘where maladministration [fault] or poor service has led to injustice or hardship, the public organisation responsible should take steps to provide an appropriate remedy’. It also says the public organisation should ‘ensure they keep any commitments to provide remedies, including ensuring they do not repeat any failures’.
35. The Trust has partly put things right as it has acknowledged the poor service and apologised for this. In terms of improving its service, the Trust said it was making efforts to improve its service.
36. We asked the Trust for more information on these improvements because the complaint response did not include much detail. We originally asked for this information in July 2023 and the Trust eventually provided it in December.
37. The Trust advised us there is a dedicated TWOC service that has appointed more staff. The service has doubled its capacity to provide TWOC slots for patients and has capacity on all weekdays. This is so the Trust can accommodate catheter removals that need doing before seven days (like in Mr U’s case).
38. The Trust also provided us with comments from the consultant urologist involved in Mr U’s care. They said they now make sure they confirm an appointment for a TWOC with the bookings team on the day of surgery. This is so the patient is aware of a confirmed date and time for the removal of their catheter. This confirmed appointment would then be on the patient’s discharge summary.
39. The information provided by the Trust so far is a good start. For us to say it has fully acted in line with our Principles, we asked the Trust how it is planning to monitor the changes and improvements it has made. For example, by using monthly reports, audits or meetings. This is so we can be sure the Trust is doing what it said it was going to do and that the changes are having the desired effect.
40. The Trust has not provided this information. So, it seems the monitoring of these service improvements has not happened. We are not assured the Trust has done enough to put things right and explain the recommendations we are making below.
1. We have carefully considered Mr U’s complaint and we are sorry to hear about his experience and how he has been affected.
2. We have seen failings in the Trust not removing Mr U’s catheter when it said it would. We understand Mr U was in a lot of pain when waiting for a trial without a catheter (TWOC) and this caused him a lot of distress.
3. We can see the Trust has apologised for not removing the catheter in a timely manner. It has also acknowledged and apologised for the significant pain he was in during this time. The Trust said it has put service improvements in place to stop this happening again. But, the Trust has not provided evidence to show how it will monitor the changes it has made. We do not think the Trust has done enough to put things right.
4. We recommend the Trust produces an action plan to show how it will monitor the service improvements it says it has made. This is so it can explain how it will stop similar failings happening in the future.
41. Our Principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. We recommend the Trust produces an action plan to show how it will monitor the service improvements it says it has made.
42. The action plan should explain what actions the Trust has taken, or will take, to prevent these failings from being repeated. The action plan should also explain who is responsible for each of these actions, when the actions will be completed and how and when the actions will be reviewed to make sure they have been completed and have had the desired effect.
43. The Trust should provide this action plan within 12 weeks of our final report. A copy of the action plan should be sent to us, Mr U, the Care Quality Commission (CQC) and NHS Improvement.