Catheterisation 21. Ms A says the Trust inappropriately catheterised her son on 10 September without any medical reason for doing so. She says the Trust continued to keep a catheter in place the rest of his admission until his death on 19 December, without justification.
22. Our neurology adviser explains there are no specific clinical guidelines that apply to this case to outline what should have happened during Mr B’s care given his condition at the time.
23. The GMC guidance outlines clinicians should provide a good standard of practice and care. It says if they assess, diagnose or treat patients, they must:
• 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
24. The NHS page on urinary catheters outlines that catheters are used when a person has difficulty urinating naturally. It outlines catheters are typically used when a patient has an obstruction in the urethra (the tube to carry urine out of the bladder), when they have bladder weakness or nerve damage, or as a last resort for treatment of urinary incontinence. The BNF treatment summary of urinary retention outlines catheterisation is used to relieve urinary retention.
25. We sought clinical advice to establish if the decision to catheterise Mr B between 10 September and 19 December was appropriate in the circumstances.
26. On 10 September at 11.13am the clinical records show Mr B’s urine cup was to be taken away to be washed and sterilised. At this point it is noted Mr B had urinated in his continence towels and placed these onto the floor. The nurse spoke to therapy staff at this point who confirmed Mr B was often wet on his person before sessions and his bed was often wet with urine. The Trust identified at 2.47pm Mr B had gone into urinary retention, which means he could not fully clear his bladder of urine, he had overflow incontinence, which is a type of uncontrolled leakage of urine. The Trust catheterised Mr B, and the records show after this he was still continuously dribbling urine.
27. Our neurology adviser explains without catheterisation at this point, Mr B would have developed back pressure on his kidneys and would have gone on to develop an acute kidney injury, which would have probably developed into renal failure had this pressure had not been relieved by the catheter.
28. We understand Ms A’s concerns her son was managing his bladder function himself and disagrees with the decision to catheterise him. We understand how distressing this decision has been for her and are sorry to hear of the distress this understandably continues to cause her. Overall we consider the decision to catheterise Mr B was in line with the GMC guidance on providing appropriate treatment given his condition at this time, and the BNF treatment summary of urinary retention.
29. We have also considered whether the decision by the Trust to keep Mr B catheterised during this period was appropriate.
30. The clinical records show following the catheterisation on 10 September Mr B also experienced a lack of bladder sensation, as shown by him not experiencing bladder pain when the catheter was blocked on several occasions and when large volumes of urine were found to be in his bladder when scanned.
31. We can see between 10 September and 19 December, the Trust’s medical team attempted bladder retraining on Mr B, which is a program designed to help patients with an overactive bladder. This was done with the use of a flip-flow valve on the urethral catheter, which is a device used to manage urinary drainage, allowing for more discreet and controlled bladder emptying. Which Mr B controlled himself.
32. The overall aim of the bladder retraining was for Mr B to gradually increase his bladder capacity. If this was achieved, he would then try a trial without catheter (TWOC). We can see Mr B experienced difficulties with using the flip-flow valve, and in the circumstances, given his reduced bladder sensation, our neurology adviser explains if he did complete a TWOC, he would again have gone into retention as he would not have been able to feel when his bladder was filling with urine. We consider it was appropriate he remained catheterised, and it was never likely a TWOC would have been successful.
33. Based on the evidence available to us, we consider there was no alternative mode of bladder management other than urethral catheterisation in Mr B’s circumstances. Had his catheter been removed and continence managed by pads there would have been inevitable risk to his kidney function, repeated urinary tract infections because of incomplete bladder emptying, and significant risk of skin damage due to urinary incontinence. Overall, the decision to keep Mr B catheterised between 10 September and 19 December was appropriate in the circumstances and in line with the GMC guidance on providing appropriate treatment, and our clinical advice supports this view.
34. We recognise Ms A’s concerns that her son remained catheterised without justification for a prolonged period and understand her strength of feeling this was unnecessary. We are sorry to hear how much this issue continues to impact her. We hope our findings in respect of this provides her with reassurances that the decision by the Trust to keep her son catheterised during this period was justified in the circumstances.
Delayed diagnosis & treatment 35. Ms A says there was a delay in the Trust diagnosing her son with a urinary tract infection and sepsis. She says when this was eventually diagnosed the Trust failed to treat this appropriately.
36. The NHS page on UTI explains diagnosis of UTI is based on a patient displaying symptoms of increased frequency of passing urine, discomfort when passing urine, pyrexia (high temperature) and more generally, a clinician’s level of awareness of the condition and how it typically presents before it is diagnosed. A diagnosis of a UTI is made through a positive urine test for bacteria.
37. In Mr B’s case any diagnosis would have been more complex as he was catheterised during his admission and did not have bladder sensation. This means he would not experience increased frequency or pain when passing urine. A patient who is catheterised and on prophylactic anticoagulation (to prevent venous thromboembolism and to prevent strokes) medication, such as Mr B, can also experience blood in the urine. Finally catheterised patients can also have bacteria present in a urine test which does not necessarily mean they have an infection, because urine becomes colonised with bacteria through catheterisation. The BNF treatment summary on UTI explains a UTI is initially treated with the oral antibiotic, trimethoprim.
38. The NHS page on sepsis outlines the symptoms of sepsis include confusion and slurred speech, blotchy skin, difficulty breathing, breathlessness or fast breathing, a rash that does not fade and a high temperature. Clinicians should carry out regular observations of a patient and monitor any deterioration by using the NEWS tool which details the level of clinical response required. A low NEWS is between zero and four, which requires an assessment to determine if increased observations are required. A medium score is between four and six and requires an urgent review and a high score is a NEWS of seven and above requires an emergency assessment. Typically, diagnosis is supported and confirmed by blood testing. The BNF treatment summary of sepsis confirms sepsis is treated with intravenous (IV) antibiotics.
39. We have considered whether there is any evidence to suggest Mr B displayed any symptoms of a UTI or sepsis prior to the Trust’s differential diagnosis of sepsis on 19 December.
40. Ms A explains how she feels the Trust missed the signs her son was suffering with a UTI and sepsis in the days prior to his diagnosis and treatment for this. We understand how important this issue is for her and recognise the worry she has about this being untreated.
41. For completeness we have carefully reviewed Mr B’s clinical records for the duration of his admission, we can see between 2 September and 15 December, Mr B did not display any signs of a UTI or sepsis. The Trust carried out frequent urine tests on Mr B which returned negative for UTI infection. We can see the Trust also carried out regular blood tests on Mr B which returned negative for infection. We consider there is no evidence of a delay in diagnosing Mr B with a UTI or sepsis during this period and our clinical advice supports this view.
42. The clinical records outline on 16 December at 4am, Mr B reported he was unable to move his legs and he had weakness in his right arm, he had a NEWS of five. The doctors reviewed him and identified he had a raised heart rate, but he did not have a raised temperature. Doctors decided to monitor him further and he was reviewed again at 4.38am when his NEWS reduced to two. At 9.28am his NEWS was one. Doctors were concerned he may have had a stroke given his overnight presentation and arranged a CT brain scan, blood tests and a urine test.
43. At 4.44pm the test results were returned, his head CT was suggestive of demyelination. The blood tests showed his white blood cell count was within normal range (5.7). He had a raised C-reactive protein of 32, which suggests he had an infection, and he had a positive Covid-19 test. Doctors wanted to wait at this point to treat his infection with antibiotics until a clear source for the infection was identified from the urine test. Our neurology adviser explains this was appropriate as the urine test results can be used to ensure the correct antibiotics are used to treat the infection and avoid the emergence of resistant bacteria.
44. On 17 December Mr B’s NEWS was one and within normal range. On 18 December at 11.54pm his neurological condition deteriorated, he unable to move his legs or trunk (the torso) and he had developed blood in his urine. His NEWS remained at one and doctors again felt there were no signs of infection. Doctors contacted the urology department at this time who confirmed there was no requirement for urgent urological treatment.
45. On 19 December at 5.41am the urine test results returned which showed Proteus (a type bacteria associated with urinary tract infections) was present in his urine so a decision was made to treat with the antibiotic Trimethoprim. Doctors discussed his condition with the acute medical team at another hospital and agreed for transfer there because of the blood in his urine and his deteriorating neurology. We are satisfied this treatment is in line with the BNF treatment summary of a UTI.
46. At 7.43am the Trust reviewed Mr B and at this point he remained in urinary retention with 598mls of urine in his bladder, it was noted he had blood in his urine and was experiencing some discomfort. Ms A explains after this point her son became unresponsive and she raised concerns to the clinicians.
47. The clinical records show a retrospective entry at 9.30am which outlines Mr B’s condition suddenly deteriorated, he had become unconscious and unresponsive and a review of Mr B was requested. He had developed an abnormal rapid heart rhythm at a rate of 180 per minute. He had a NEWS of 16 and the Trust’s differential diagnosis at this time was sepsis. A differential diagnosis is the process of systematically identifying potential conditions that could explain a patient’s symptoms, then narrowing the list through clinical reasoning, testing, and elimination. From reviewing the evidence available, it does not seem there was ever a formal diagnosis of Mr B having sepsis during his admission.
48. After the differential diagnosis, he was intubated and doctors started him on IV antibiotics. Despite this treatment, Mr B continued to deteriorate and sadly died later that day. Overall the Trust acted promptly when Mr B’s condition deteriorated suddenly and treated him with antibiotics, and our clinical advice supports this view. We consider this treatment was in line with the BNF treatment summary on sepsis.
49. We understand Ms A’s concerns about whether the Trust could have identified that Mr B had either a UTI or sepsis much sooner than it did. We have carefully considered this point further, we know in her complaint to us Ms A explained how quickly her son deteriorated on 19 December and she explains how she realised at this point he was dying, and we acknowledge how upsetting this must be for her. We are sorry to hear about how much she continues to be impacted by this. It is clear from speaking to her how important this issue is for her.
50. We have seen no evidence to suggest the Trust should have diagnosed Mr B with a UTI or sepsis sooner than it did. We are satisfied the Trust carried out appropriate testing between 2 September and 16 December, and the results of this did not indicate he had a UTI or sepsis, and our clinical advice supports this view.
51. We consider in the days prior to his death between 16 December and 19 December, there was no delay in the Trust diagnosing a UTI or sepsis. When the Trust reached a differential diagnosis he had a UTI and sepsis on 19 December in the final hours of his life the Trust treated this appropriately with antibiotics. We have seen no evidence the Trust should have diagnosed Mr B sooner than it did in this period.
52. We hope our findings in relation to this reassure Ms A that the Trust were carrying out appropriate investigations during this period.
Physiotherapy 53. Ms A says the Trust failed to provide appropriate physiotherapy to her son during his admission by not maintaining his mobility.
54. The HCPC guidance outlines physiotherapists should:
• complete a robust assessment of a patient to determine the appropriate level of physiotherapy • practice safely and effectively within their scope of practice • respect the rights of a patient • provide a level of dignity to service users • work appropriately with other colleagues and contribute to the work undertaken as part of a multi-disciplinary team • evaluate care plans and revise the plans as necessary
55. Overall, there should be a robust level of physiotherapy provided throughout an admission to aid recovery.
56. The clinical records show on 2 September the Trust completed a referral to its therapy team to provide Mr B with inpatient physiotherapy. The referral was triaged by the therapy team and the Trust completed an assessment of Mr B on 4 September.
57. The assessment documents show the therapy team reviewed Mr B’s overall level of mobility, completed a stroke and neurological assessment, reviewed his range of movement and power and worked with him to create his overall goals for therapy. The results of this were then used to create a therapy plan for him. We can see the assessment was thorough and robust, taking clear consideration of his overall condition at the time. This initial assessment was in line with the HCPC guidance on completing a robust assessment of a patient, and our clinical advice supports this view.
58. We can see between 4 September and 14 December, Mr B was reviewed almost daily by the physiotherapy and occupational therapy teams. Each session lasted between 45 and 60 minutes and involving a total of three members from the therapy team. The physiotherapy sessions included a mix of exercises and functional training such as rolling, sitting unsupported and standing with relevant equipment. Mr B’s goals were discussed with him regularly and reviewed in a weekly MTD meeting.
59. The documents indicate the Trust took a collaborative approach to Mr B’s therapy and we can see evidence of the therapy teams working closely together throughout his admission to ensure he received a good standard of physiotherapy. We consider this is in line with the HCPC guidance on work appropriately with other colleagues and contribute to the work undertaken as part of a multi-disciplinary team.
60. We can see specifically on 21 October it was identified that Mr B was not progressing with his rehabilitation, and the team agreed he would benefit from a further three-week period of more structured therapy and for Mr B to take more responsibility for his recovery, such as sitting out of bed more and doing more for himself. This is in line with the HCPC guidance on evaluating care plans and revising them as necessary.
61. Mr B continued to receive regular physiotherapy after this period until 14 December, when he became too unwell to participate in the therapy sessions. Between 14 December until his death on 19 December, the therapy teams continued to discuss Mr B during the weekly MDT sessions.
62. The evidence shows the Trust were respectful of Mr B’s condition throughout and ensured he received continuity in care in rearranging any missed appointments to ensure they were followed up on. We consider this is in line with the HCPC guidance on respecting the patient and our clinical advice supports this view.
63. Overall, we consider the Trust provided an appropriate level of physiotherapy to Mr B during his admission in line with the guidance, and our clinical advice supports this view.
64. Ms A explains how upsetting it was to see her son’s condition deteriorate during his admission, we understand how important this issue is for her and are sorry to hear how much this continues to impact on her. We hope our findings provide Ms A with reassurances over the standard of physiotherapy provided to her son during his admission