Catheterisation
18. Miss O complains the Trust failed to gain consent from E for catheterisation, and it attempted to force catheterisation.
19. The Trust’s letter of 13 June 2022 is a written summary of what happened at a complaint meeting on 1 March. The Trust recognised it did not provide E with a clear explanation of what the clinical team were doing during the catheterisation procedure. It also explained that, for certain procedures, it does not require written consent but acknowledged it should have communicated more for clearly with E. In a later entry in E’s medical notes, it says E expressed the experience on 24 June 2021 was awful and unpleasant, and not the same as previous attempts at catheterisation.
20. The RCN guidance says that ‘catheterisation is an invasive procedure with associated serious risks, therefore obtaining documented, valid consent is vital prior to the procedure’. It also says ‘the patient should understand the rationale, the alternatives and the consequences of not being catheterised’, as this enables the patient give informed consent. This guidance reiterates several times that nurses ‘need to record clearly, accurately and correctly any relevant information in ongoing patient/person or urinary care records’.
21. Examples of what nurses should consider including in their documentation are:
• ‘The reason for catheterisation, catheter change or ongoing need for a catheter with all its risks’ • ‘The results of any risk assessment prior to catheterisation’ • ‘The health status of the patient prior to catheterisation – well/unwell’ • ‘Is the individual patient in any form of localised discomfort or pain?’
• ‘Has consent been obtained for the procedure? Some organisations now require this to be in written form’ • ‘If the insertion was easy or difficult’.
22. The NMC code can also be applied here. Sections 1, 1.1, 1.2 and 4.2 are as follows:
• ‘treat people as individuals and uphold their dignity’ • ‘treat people with kindness, respect and compassion’ • ‘make sure your deliver the fundamentals of care effectively’ • ‘make sure that you get properly informed consent and document it before carrying out any action’.
23. We cannot see any documentation in the medical records of when members of staff attempted to catheterise E on 24 June. There is also no documentation to say whether staff explained the reasons for catheterisation to E and if it gained consent for the procedure. This contrasts with a previous entry in the medical notes on 18 June, where it is documented that two attempts at catheterisation were unsuccessful.
24. Without any documentation to say what happened during the catheterisation on 24 June, it is difficult for us to say exactly what happened. As such, we have considered other entries in the medical records to help us reach a decision.
25. There is an entry on 24 June at 10.12pm where the on-call doctor was asked to review E ‘as she was not … able to be catheterised’. This notes E as being very upset and tearful about the situation as catheterisation was tried four times. The doctor notes that catheterisation would not be tried again on that day, and reassured E that they would not force this.
26. In the ward round notes the following day (by a different doctor), it says E is still tearful and upset about what happened the night before. The doctor is ‘unsure WHY a catheterisation was even attempted … it was not part of the medical plan as patient is not known to be on long-term care/retain urine. [Also] unclear from nursing entries WHY catheter was attempted’. The doctor noted there was ‘NO INDICATION’ for a catheter and that it would not be reattempted. (Original emphasis in medical notes.)
27. There is a further entry on 25 June which notes that E advised the staff she did not consent to the catheterisation attempts on 24 June and did not think she was retaining water. Therefore, she did not understand why the attempted catheterisation needed to happen. It is also noted that E felt the nurse wanted to do it [catheterisation] because it was too much to change her.
28. We have considered the evidence from the medical records, what the Trust has said, and Miss O’s account of events. On balance, it is likely that the Trust did attempt catheterisation and that this was not carried out in line with the guidance. As per the RCN guidance and the NMC code, if E had been made aware of the rationale behind attempting catheterisation and was aware of the risks and benefits, only then could she have given informed consent.
29. We cannot say with certainty whether the Trust ‘forced’ E to be catheterised. This has been made more difficult due to the lack of any record about the attempted procedure. However, the other notes explain how E felt about what happened at the time (she says she did not consent), and they also show there was no clinical indication for her to be catheterised. This provides further evidence for us to say that the Trust did not carry out the procedure as it should have done.
30. We consider this a failing in the Trust’s treatment of E.
31. Miss O says the catheterisation caused E to suffer from severe bleeding. She says it also caused her psychological harm where she felt abused and scared to have future medical treatment.
32. Miss O says that when a doctor examined E after, he had asked her whether she was menstruating due to the amount of blood he was seeing. The RCN guidance explains that one of the catheter-associated complications can be bleeding. However, there is no note of any blood or bleeding of the entry site of the catheter after the catheterisation attempts on 24 June. There is also no note of any physical examination of E and the entry site of the catheter.
33. The lack of notes here makes it difficult for us to say whether there was any bleeding or blood, and if an examination took place. The only note is the on-call doctor’s review on 24 June after the failed catheterisation attempts. It is noted that analgesia (pain-relief) was given ‘for catheter site soreness’. We only have Miss O’s account that there was any bleeding.
34. Regardless, our adviser says that the insertion of a catheter can be uncomfortable and painful. Considering catheterisation was attempted four times, it is likely that E must have been in a lot of pain. This is also reflected in Miss O’s account, which says that the catheterisation attempts caused E severe pain.
35. Our adviser explains that as the Trust did not gain the appropriate consent, did not explain the procedure and why it happened, it can affect the patient’s privacy and dignity as catheterisation is an invasive procedure. The lack of consent can also compound the psychological and emotional impact of this procedure on the patient.
36. It is clear from the notes E was significantly affected by what had happened, and felt it was a very serious situation. So much so that the Police were called to attend. Overall, it is understandable that E had felt scared to have future medical treatment.
37. The Trust has acknowledged the poor communication provided to E regarding the catheterisation attempts on 24 June and apologised for this. However, we do not think this sufficiently recognises the significant impact the Trust’s actions had on E, and for the rest of the family (E is now deceased). Nor does it reflect the seriousness of the complaint made. We do not think the Trust has done enough here to put things right and we will outline our recommendations later on in the report.
Complaint Handling
38. Miss O complains about delays in the Trust’s handling of her complaint.
39. The Trust’s complaint policy outlines the timeline of what happens when it receives a complaint. It says it will acknowledge the complaint within three working days, and that it will provide a response within 30 working days. The Regulations say that organisations should provide a response within six months from when the complaint was received. If the organisation cannot provide a response within this time, it should let the complainant know the reasons why.
40. Our Principles of Complaint Handling say that public organisations should ‘deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate’.
41. Miss O complained to the Trust on 6 July 2021, and received an acknowledgement on the same day. In its acknowledgement letter, it gave a timescale of 65 working days for providing a response upon receiving consent from the patient. It advised that due to the challenging situation facing the Trust at the time (COVID-19 pandemic), it may take longer to provide a response. If so, it would contact Miss O to extend the completion date.
42. The Trust emailed Miss O on 23 July asking if it can arrange a complaint meeting, and to get E’s consent for this to happen. Miss O emailed the Trust on 26 July to confirm she had obtained consent from E. Miss O emailed the Trust again on 26 August to ask whether it had managed to arrange a date for the meeting and it had not. She contacted the Trust on 27 October to inform them that E had died and asked the Trust to still proceed with arranging the meeting.
43. The Trust emailed Miss O on 7 January 2022 about arranging the meeting. Several emails were sent back and forth over the course of the month, until a meeting was confirmed for 1 March. After the meeting, Miss O sent further queries for the Trust to investigate. Miss O contacted the Trust on 22 March as she had not received anything following the meeting. The Trust responded the next day advising the CD will be sent shortly, and to confirm the further investigation points.
44. Miss O received an email from the Trust on 8 April advising that the summary letter was being drafted, and that it should be with her soon. She chased the Trust again on 6 May and 8 June, as she had not received anything. The Trust’s complaint letter is dated 13 June, which Miss O received on 24 June.
45. The Trust received consent from E on 26 July 2021, so it had 65 working days to provide a response from then. This meant that it should have provided a response by 26 October if following its own estimations (if 30 working days, as per its own policy, it should have been sooner). If taking into account the Regulations, it should have provided a response by the end of January 2022.
46. The Trust’s response is dated 13 June 2022, which is significantly over the timescales provided by its own policy and the Regulations. This is also not in line with our Principles of Complaint Handling.
47. We appreciate it can take some time to arrange a complaints meeting with all the relevant clinical and non-clinical staff due to busy schedules, especially during the COVID-19 pandemic. However, from when the Trust first suggested the meeting (23 July 2021) to when it was confirmed (4 February 2022), this does seem excessive. The Trust has not provided us with any information to show it had contacted Miss O asking for an extension to provide a response, either before or after the meeting.
48. Overall, the Trust did not provide a complaint response in line with the relevant standards. Therefore, we consider this a failing.
49. Miss O says the complaint handling delays prevented her and her family from grieving E’s death.
50. Our Principles of Complaint Handling say that ‘resolving problems and complaints as soon as possible is best for both complainants and public organisations’.
51. Going through the complaints process can be stressful and distressing, especially when having to go over upsetting events. By not being able to complete the complaints process in a timely manner, we appreciate this compounded the distress at an already distressing time.
52. The Trust has apologised that Miss O had to wait so long for a complaint meeting to take place, however we do not think this sufficiently recognises the significant impact this had on Miss O and for the rest of the family. Especially as E had died not long after Miss O had originally complained to the Trust. We cannot imagine how hard this whole situation must have been for Miss O and the family, and consider the Trust has to take further actions to recognise the impact its actions caused.