Royal Devon University Healthcare NHS Foundation Trust

6. Mr B complains Royal Devon University Healthcare NHS Foundation Trust inappropriately changed a planned anaesthetic when it attempted to insert a suprapubic catheter in December 2023.

7. He says the change in the procedure meant the Trust missed his bladder when it inserted the catheter needle and instead it hit a vein which caused trauma and bleeding. He told us he was traumatised by the experience, it was very uncomfortable and distressing and has triggered his post-traumatic stress disorder (PTSD).

8. He says his genital area was extremely bruised and it was worrying to see the catheter bag full of blood. He told us he was very unwell following the procedure and needed emergency treatment. He told us the experience has left him feeling very vulnerable, fragile, anxious, and apprehensive about future surgeries. Mr B wants a financial remedy.

9. This very brief background is only intended to place the key events in context, not to provide a full, chronological account of everything that happened.

10. Mr B has a past medical history of high blood pressure, diabetes, spinal cord injury, post-traumatic stress disorder (PTSD) from a previous traumatic experience in the workplace, seizures, tetraplegia (a severe form of paralysis that affects the arms and legs due to a spinal cord injury), and had a urethral catheter (a small tube that passes through the urethra (waterpipe) and into the bladder to drain urine into an external bag).

11. The Trust reviewed Mr B in August 2022 and decided he needed a cystoscopy to look inside the bladder using a camera. It also decided it needed to change his catheter to a suprapubic catheter under general anaesthetic. A suprapubic catheter is a small tube inserted directly into the bladder through the skin in the lower abdomen to drain urine without it passing through the urethra. This is for patients who have conditions that mean they can no longer pass urine through their urethra. General anaesthetic is a combination of medications that cause controlled unconsciousness allowing patients to undergo surgical procedures without awareness or pain.

12. The Trust carried out three anaesthetic assessments for Mr B during 2023 and admitted him in December for the procedure. The Urology team spoke with Mr B and his wife on the day of his admission and decided to carry out the procedure under a local anaesthetic and ultrasound guidance rather than general anaesthetic. Local anaesthetic is medication that numbs an area of body and leaves the patient conscious during a procedure. The Trust attempted the procedure, but it was unsuccessful, so it abandoned it.

13. Mr B’s blood pressure (BP) dropped when he was on the ward following the procedure. It is unclear from the medical records how soon after the procedure this happened. The Trust carried out a CT scan which showed a lower anterior abdominal haematoma, which is bleeding that occurs within the stomach or stomach wall. The Trust’s psychiatric team reviewed Mr B two days later as he had explained to staff the procedure had triggered his PTSD and caused him distress. The Trust discharged Mr B the following day.

16. Mr B complains the Trust changed the planned anaesthetic for his procedure to insert a suprapubic catheter in December 2023. He says the Trust should have carried out this procedure under a general anaesthetic but instead it used a local anaesthetic.

17. He told us that the procedure was not successful when he was in theatre, and the Trust had to abandon it. He says this was extremely distressing and painful as he was awake during the procedure. We were sorry to hear Mr B’s concerns about how the Trust managed his anaesthetic for his procedure and the impact this had on him because he was awake. From what he told us, it is clear that he found this experience distressing.

18. BAUS guidelines on inserting suprapubic catheters say clinicians should use a general or regional anaesthetic for patients who have had a spinal cord injury and if the bladder cannot be comfortably filled with at least 300ml of fluid. A regional anaesthetic is a type of anaesthetic such as a spinal anaesthetic that numbs parts of the body but allows the person to stay awake during the procedure. Mr B had a spinal cord injury so this guideline would apply to his procedure.

19. Our adviser explained that clinicians usually use a general anaesthetic for patients who have a suprapubic catheter insertion who have a spinal cord injury as they are at risk of a condition called autonomic dysreflexia. This is a condition where the patient’s BP rises suddenly and happens as a response to pain or discomfort below the level of a spinal cord injury. It can be potentially harmful and people with spinal cord injuries have a higher risk of experiencing it. Clinicians therefore use general anaesthetic, so the patient is unconscious and does not feel any pain or discomfort during the procedure to cause this condition.

20. The BAUS patient advice leaflet says there can be various aftereffects from suprapubic catheter insertion. This includes bladder spasms or bladder pain and accidental damage to other parts of the body such as the bowel or blood vessels.

21. The Trust reviewed Mr B in clinic at the beginning of August 2022 and listed him for a cystoscopy and suprapubic catheter insertion under general anaesthetic. The Anaesthetic team assessed him in August 2023, and twice in September before his planned procedure to check he was medically fit enough to have a general anaesthetic.

22. The Team noted that Mr B was at higher risk for complications during a general anaesthetic than an average patient due to his existing conditions, but it was happy to proceed with a general anaesthetic for his suprapubic catheter procedure. It noted that Mr B preferred a spinal anaesthetic, if possible, where medication is injected into the area around the spinal cord to numb the nerves in the lower body.

23. In mid-December, the Trust admitted Mr B for his suprapubic catheter procedure. It reviewed him on the ward before his procedure and discussed the option of carrying it out under local anaesthetic instead of general anaesthetic with him. The Trust said as it felt this was a safer option due to his other conditions and decided to proceed with the suprapubic catheter procedure only, under a local anaesthetic.

24. During the suprapubic catheter procedure under local anaesthetic, the Trust was only able to fill Mr B’s bladder to 240ml to proceed with the procedure. This was because he found this painful, so it stopped filling his bladder any further. This procedure usually needs the bladder to be comfortably filled to 300ml as set out in the BAU guidelines above, so this can be drained through the suprapubic catheter. The Trust attempted to insert the suprapubic catheter but could not drain any urine from the bladder, so it tried again. It did not successfully drain any urine on the second attempt either.

25. The Trust noted that Mr B’s bladder was shrunken, and it was a challenging procedure. It decided to stop the procedure and reinserted a urethral catheter. It organised a CT scan to make sure it had not injured any other organs during its attempt to insert the suprapubic catheter. The CT scan showed a 5 x 8 cm haematoma (collection of blood) near Mr B’s bladder.

26. The Trust reviewed Mr B following his procedure, and during this assessment his BP dropped, and he was cold, clammy, and sweaty. He was unresponsive for between one and two minutes, so the Trust made a cardiac arrest call due to his unresponsiveness.

27. The Trust monitored Mr B, and his BP started to improve, and he was conscious following this episode. It is understandable that this must having been significantly distressing for Mr B, and we were sorry to hear how scary this experience was for him.

28. One day after his procedure, Mr B asked the Trust for a referral to the Psychiatric team because the experience triggered his PTSD. The Psychiatric team reviewed him the following day. During the assessment, Mr B explained that his surgery was not successful, and he felt brutalised during it which triggered his PTSD. He said being awake during the procedure increased the psychological impact on him. The Team reported that Mr B felt a positive benefit from its input.

29. From the evidence we have seen, the Trust did not follow BAUS guidelines on suprapubic catheter insertion. This is because it did not carry out Mr B’s procedure under general anaesthetic despite his spinal cord injury and the fact it was not able to comfortably fill his bladder to 300ml as he found it painful when the Trust filled it to 240ml.

30. The guidance says clinicians must use a general anaesthetic in these circumstances, and we cannot see any evidence it considered these reasons on the day of the procedure to continue with a general anaesthetic as it originally planned. The Trust should not have carried out Mr B’s procedure under a local anaesthetic and its decision to do this is a failing.

31. As we have seen that something went wrong when the Trust carried out Mr B’s procedure under local anaesthetic instead of general anaesthetic, we have gone on to consider how this impacted him.

32. Mr B told us the Trust missed his bladder when it attempted to insert the suprapubic catheter and hit a vein which caused him trauma and bleeding. He said this was extremely distressing and uncomfortable. He said the Trust also caused bruising on his genitals. He said that as he was awake during the procedure, he witnessed what went wrong and this impacted his mental health as it triggered his PTSD.

33. He told us what about what happened when he felt unwell following his suprapubic catheter procedure and how he needed emergency treatment which was very distressing and worrying for him. He explained the experience made him feel very vulnerable, fragile, and anxious about future surgeries.

34. We were sorry to hear Mr B’s account of what happened and how this impacted his mental health. From what he told us, it is clear this experience was significantly distressing for him when the Trust could not insert the suprapubic catheter, and he was very unwell following the procedure. It is understandable that his concerns continue to impact him.

35. Our adviser explained the Trust should have carried out Mr B’s suprapubic catheter procedure under general anaesthetic because of his spinal cord injury and the Trust was not able to fill his bladder to 300ml. They went on to explain that the Trust’s choice of anaesthetic does not appear to have caused the haematoma that Mr B experienced during the attempted suprapubic catheter insertion.

36. This is because damage to blood vessels is one of the complications of a suprapubic catheter insertion, as listed in the BAUS patient information leaflet above and this could have happened despite the choice of anaesthetic, and we consider this complication was unavoidable. This means we cannot say the Trust’s choice to use a local anaesthetic caused the damage to Mr B’s blood vessels or the bruising to his genitals, as this risk (damage to other body organs), is a risk of the procedure itself rather than a risk of the anaesthetic.

37. Our adviser went on to explain that it is difficult to say if Mr B’s episode of low BP after the procedure was linked to the impact of him having a haematoma, his spinal cord injury, or the aftereffects of having a procedure in general.

38. As we explained above, people with spinal cord injuries are at a higher risk of autonomic dysreflexia, however, the symptoms of this condition usually include a rapidly increasing BP rather than a drop in BP like Mr B experienced. This means we cannot confidently say whether or not this happened because of the Trust’s choice of anaesthetic. We are sorry if this is disappointing for Mr B.

39. Our adviser explained that it does not appear the Trust’s decision to use a local anaesthetic caused Mr B any clinical long-term physical damage, as he is waiting to have the suprapubic catheter procedure at another hospital. It is difficult for us to say if the procedure would have been successful under general anaesthetic so we cannot say if the need for a second procedure to have the suprapubic catheter inserted at another hospital could have been avoided with different action from the Trust.

40. However, Mr B was awake during the unsuccessful suprapubic catheter procedure and aware of what happened during it. From what he told us this clearly caused him distress and this could have been avoided had the Trust used a general anaesthetic.

41. Our adviser explained the suprapubic catheter procedure under local anaesthetic at the Trust impacted Mr B emotionally and mentally because it caused him distress. This is supported by the fact he asked for input from the Psychiatric team to support him due to the amount of distress he experienced.

42. We have seen further evidence to support that Mr B also experienced the pain he told us about during his procedure as the medical records document he was in pain when the Trust attempted to fill his bladder. We consider Mr B may not have experienced the pain and distress he told us about if the Trust had used a general anaesthetic in line with the BAUS guidance above. We consider his distress, pain, and anxiety about future surgeries could have been avoided with different action.

43. Based on what we have seen, the Trust’s decision to change its choice of anaesthetic for the suprapubic catheter procedure caused Mr B some but not all of the distress he told us about. This is because it is difficult for us to say how much of his distress he experienced happened because of the episode after the suprapubic catheter procedure when his BP dropped and he felt very unwell. We imagine this was significantly distressing for him especially as he was unresponsive for between one and two minutes and added to the overall distress he experienced. Sadly, we cannot directly link this to the choice of anaesthetic itself so we cannot take this into consideration.

44. Our Principles of Remedy say that to put things right, organisations should provide an apology, explanation, and an acknowledgement of responsibility.

45. In its response to the complaint, the Trust explained that it carried out Mr B’s suprapubic catheter procedure under a local anaesthetic as it felt it was a safer and less complicated option because of his existing conditions.

46. It apologised if he felt the Trust had fallen short of the high standards it sets itself. It said based on Mr B’s complaint if planned to share his concerns for learning and review the pre- and post-surgery information it gives to patients to help them feel well informed. This is in line with our Principles. However, the Trust does not acknowledge what went wrong or how its choice of anaesthetic impacted Mr B when it caused him distress and pain.

47. Based on the available evidence and the clinical advice, we consider the Trust did not follow relevant guidance when it made the decision to change Mr B’s suprapubic catheter procedure from a general anaesthetic to a local anaesthetic on the day of the procedure. It did not consider his spinal cord injury or his bladder capacity when it made this decision, which the guidance says it must.

48. Although we do not think the failing led to all of the impact Mr B told us about, we cannot see the Trust has acknowledged what went wrong or how this caused him distress and pain. Therefore, we partly uphold this complaint and make recommendations at the end of our report, as we can see that something went wrong that has not been fully remedied by the Trust.

49. It is clear from our conversations with Mr B that he found his experience at the Trust significantly distressing and we would like to thank him for taking the time to bring his complaint to us. We do not underestimate how difficult it has been for him to share his concerns with us as it is clear that his experience at the Trust continues to worry him. We hope our findings help to clarify any information he was unsure about.

1. Mr B complains the Royal Devon University Healthcare NHS Foundation Trust (the Trust) changed the planned anaesthetic for his catheter insertion procedure in December 2023. He is understandably concerned that the Trust’s choice of anaesthetic caused him to experience pain and distress during the procedure, and a significant episode of low blood pressure following it.

2. We were sorry to hear about what happened and how Mr B’s concerns about the Trust’s actions continue to cause him ongoing distress. From what he told us, it has clearly been a difficult time for Mr B, and his experience following his procedure was significantly distressing for him.

3. We have seen the Trust did not follow relevant guidelines when it carried out Mr B’s catheter insertion under a local anaesthetic and we consider this action by the Trust led to some of the impact Mr B told us about.

4. We can see the Trust has apologised for Mr B’s experience and said what it has done so far to improve its service. However, we do not consider that it has fully acknowledged what happened or reflected on the impact this failing had on Mr B. Therefore, we partly uphold this complaint and make recommendations at the end of our report.

5. From what Mr B told us, it us understandable that his experience at the Trust caused him distress, pain, and anxiety about future surgeries. We hope our report helps to answer his concerns and clarifies any information he was unsure about.

50.We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

51.Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

What we found 52.Through investigating Mr B’s complaint, we found:

• The Trust missed an opportunity to follow relevant guidelines on suprapubic catheter insertion and carry out Mr B’s procedure under a general anaesthetic and this led to some of the distress and pain Mr B told us about.

What the organisation should do 53.Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

The Trust should write to Mr B to:

• acknowledge the failings we have found in relation to it not following BAUS guidance and using a local anaesthetic instead of a general anaesthetic for Mr B’s procedure • send a copy of this letter to us by 16 January 2026.

54.Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

Following this review, we recommend the Trust:

• pay Mr B £500 in recognition of distress, worry, and pain he experienced when it decided to use a local anaesthetic instead of a general anaesthetic • send us evidence it has done this by 16 March 2026.