Monitoring and removal of catheter
34. Mr P raised concerns that once the Trust inserted a catheter it failed to monitor and remove this appropriately.
35. We are very sorry to hear about Mr P’s experience and understand the impact this had on his everyday life.
36. The Trust said Mr P should not have had a catheter inserted straight after surgery but apologised for any communication issues once his catheter was inserted about who to turn to for help and support.
37. We understand Mr P’s water retention began on 1 December 2022 and he attended A&E due to the severe pain he was in. It was at this point, the Trust catheterised Mr P.
38. The Trust told Mr P he would be contacted by the trial without catheter (TWOC) team to arrange its removal. However, the TWOC team were unable to assist Mr P due to where he lived, and this was the same for the district nurses. Mr P therefore contacted his GP, who referred him to the continence team, but they were also unable to assist. Mr P therefore went back to the Trust which said it would remove the catheter but could not monitor him. The Trust removed the catheter on 8 December 2022.
39. NHS guidance on catheter insertion says, ‘If you need a long-term urinary catheter, you'll be given detailed advice about looking after it before you leave hospital. This will include advice about getting new catheter supplies, reducing the risk of complications such as infections, spotting signs of potential problems, and when you should get medical advice.’
40. Our adviser also said that, prior to discharge, the Trust should have ensured Mr P would have adequate follow up and safety net care in the community, if he required help. Not doing so was not in line with the NHS guidance above. We therefore consider this to be a failing as the Trust did not appropriately monitor Mr P nor did it provided him with appropriate information for who he could turn to with any issues and monitoring.
41. As previously stated the first catheter was removed by the Trust on 8 December. However, due to further urinary retention a new catheter had to be fitted later that day. This was later removed on 15 December and a new catheter was fitted on 19 December due to urinary retention. This catheter remained in place until 20 January.
42. The NICE guidance says, ‘The patient's clinical need for catheterisation should be reviewed regularly and the urinary catheter removed as soon as possible.’
43. Our adviser added the Trust needed to catheterise Mr P as he was in urinary retention. When it tried to remove the catheter, a matter of hours or days later he would go into urinary retention and need to be re-catheterised.
44. The NICE guidance adds when a catheter is in place for more than four weeks this becomes classed as long term use and there is a greater risk of complications.
45. We therefore consider there is a failing here with the catheter the Trust put in place on 19 December as this was not removed until 20 January, which is greater than four weeks. The Trust made no provision to review the need for catheterisation in this period nor consider whether it could be removed.
46. We understand it may be difficult for Mr P to read that the Trust did not appropriately care for him during the time between 1 December 2022 and 20 January 2023.
47. We now need to consider the impact of the Trust’s failing to appropriately monitor and remove Mr P’s catheter.
48. Mr P said that due to the catheter being in place for longer than it should have been he suffered pain, bleeding, and calcification of the catheter. He said he needed to attend A&E several times and had to pay for a private consultant to monitor and remove his catheter.
49. Mr P also says this affected his mood, he felt low and became worried his catheter would leak so did not like to leave the house.
50. We are sorry to hear how this situation impacted Mr P during this time. We can understand how the worry he felt having a medical device fitted without knowing who would care for that device.
51. The NICE guidance says if a catheter is left in place for longer than four weeks it is classed a long term catheter which increases the risk of:
• ‘Infectious complications: catheter-associated urinary tract infections (CAUTIs) • Non-infectious complications • leakage of urine (bypassing) • catheter blockage • accidental dislodgement.’
52. When Mr P attended A&E regarding his catheter it is documented he was in severe pain. Our nursing adviser said this pain and discomfort would have been caused by the catheter. However, we do not consider Mr P was in severe pain every day from 1 December 2022 to 19 January 2023. Mr P attended the Trust four times during this time due to the pain he was in, and received care. We therefore consider Mr P suffered pain for around one week of this time period.
53. With regards to Mr P’s catheter calcifying, his medical records detail ‘there was grit around the catheter itself and quite a significant amount.’ There are also notes to say Mr P had been passing bits of what he thought was calcification. We therefore consider his catheter had started to calcify.
54. Our adviser added that as Mr P’s catheter had started to calcify this would have caused Mr P’s catheter to become blocked. The Oxford guidance says blockage of catheters could have caused obstruction of the flow of urine from the bladder, which could have caused pain, bypassing of urine (leaking) and possible infection.
55. However, despite Mr P suffering from calcification, the NHS guidance says calcification can occur due to many different factors including poor fluid intake, constipation or infection. Therefore, we cannot say it was the poor management of Mr P’s catheter caused it to calcify.
56. Mr P has also said due to the failing with the Trust not monitoring and removing his catheter appropriately, he had to attend A&E on multiple occasions. We can see Mr P had to attend A&E during the months of December and January whilst his catheter was in place due to pain. We would consider this would not have been the case if Mr P’s catheter had been appropriately monitored in the community.
57. As stated previously, we can see Mr P had to attend A&E four times during this time period. Therefore, out of the seven weeks he had a catheter this impacted him over four days.
58. We also consider not having his catheter appropriately monitored or removed when it should have been would have had an impact on Mr P wanting to leave the house due to a risk of leaks. As stated previously, leaks are a risk when a catheter had been left in place for too long. We would then also consider that being worried to leave his house would have had an impact on his mood and everyday life.
59. In terms of Mr P Mr P needing to see a private consultant to monitor his catheter. Mr P contacted a private consultant in January 2023, which cost £250 and they removed the catheter on 23 January 2023, which cost £175. Mr P then had a follow up appointment to check everything was ok after the catheter was removed, this cost an additional £175. Mr P has therefore spent a total of £700 on private care due to not receiving the appropriate care from the Trust.
60. We considered whether it was reasonable for Mr P to seek private treatment. Where people have incurred private costs we do not automatically recommend reimbursement. We need to think about whether those costs were necessarily incurred and whether the NHS had sufficient opportunity to provide the care or treatment required.
61. In this case our view is that Mr P gave the NHS appropriate time to provide him with the monitoring and care he needed whilst he required a catheter. During the period of the complaint, he clearly wanted the NHS to take responsibility for his catheter care. We have explained that responsibility lay with the Trust. However, despite Mr P’s efforts, this did not happen. We do not think it unreasonable that Mr P should believe the NHS had abdicated responsibility for his care. We therefore consider it is justified that Mr P sought care and treatment from a private provider. We note Mr P did not turn to that option with undue haste. Mr P’s catheter was first inserted on 1 December 2022 and he did not contact a private consultant until 9 January 2023. During this time, he had to attend A&E on multiple occasions and was told different information by the Trust about where responsibility for his catheter care sat. This resulted in him not being monitored in the community. Our view is that Mr P reasonably incurred those costs as a result of the Trust’s failings.
Complaint handling
62. Mr P also raised concerns about the way in which the Trust handled his complaint. He says the Trust delayed a response to his complaint, did not provide a written response and closed the complaint without agreeing any resolution.
63. We understand how frustrating this would have been for Mr P and that he feels let down by the Trust.
64. The Trust PALS team received Mr P’s complaint, and consent for Mrs P to act on his behalf, on 23 January 2023.
65. Mr and Mrs P chased PALS a number of times for a response and on 26 February 2023 spoke to someone in the Patient Experience Team who said the matter was with the lead investigator but they could not provide a timescale for completion, as pre-COVID timescales did not apply.
66. The Lead Investigator then contacted Mr P on 4 March 2023, which is just over one month after the Trust received Mr P’s consent form.
67. We then understand the Trust issued an investigation report in April 2023 which provided details of lessons learnt from Mr P’s complaint. Therefore, the time between Mr P complaining and the Trust providing its investigation report was 23 January 2023 to April 2023. Our NHS Complaint Standards say organisations should respond at the earliest opportunity. The NHS complaints regulations also says organisations should let people know if an investigation is going to take more than six months, which was not the case here.
68. As the Trust provided its response to Mr P’s complaint just over two months after it was received, we consider this was in line with both our NHS Complaint Standards and the NHS regulations. Overall, we consider the Trust did provide a timely response to Mr P’s complaint and did so in line with guidance.
69. Following the investigation report Mr P remained unhappy and responded on 14 June 2023. The Trust arranged a meeting with Mr and Mrs P for 22 September 2023. Following the meeting, Mr and Mrs P had to chase the Trust for a transcript of the meeting. The Trust told them in December 2023 that the complaint had been closed.
70. The minutes from the meeting do not detail what was agreed between the Trust and Mr P in terms of any follow up resolution letters or if the complaint was to be closed. As we were not there at the time, we also do not know what was discussed. However, it is clear from Mr P chasing the Trist directly and through his MP that he was expecting some further communication from the Trust with regards to his complaint.
71. Our NHS Complaint Standards says an organisation should, ‘agree how people will be kept informed and involved.’ We consider the Trust did not adequately communicate with Mr P during the meeting on 22 September 2023 as to what the next steps would be, if there were going to be any. We consider this is a failing.
72. Overall, we do consider the Trust provided a response within a timely manner and did respond to Mr P’s complaint in its investigation report in April 2023. However, we do not consider the Trust appropriately communicated it was going to close Mr P’s complaint following the meeting in September 2023. We will consider the impact of this next.
73. Mr P said that due to the failings in the way the Trust handled his complaint he was left with stress and frustration.
74. We consider this impact to be plausible. Mr P attended a meeting in September 2023 and there is no evidence to suggest Mr P was informed of next steps or that his complaint was going to be closed. We therefore consider this would have caused him some stress and frustration.
75. Our severity of injustice scale says level one, ‘A case will generally be level one if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience. This would typically arise from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact.
We will usually consider an apology to be an appropriate remedy for these cases.’
76. We consider the frustration caused when finding out the complaint was closed did not effect Mr P every day, and would not have impacted his normal, every day life throughout this process. We consider it took time for Mr P to chase his complaint and take time out to respond to the Trust but we do not consider this took enough time to be classed as level two within our severity of injustice scale. Our recommendations below reflect that an apology is sufficient to put this right.