Problems removing Mrs H’s catheter and a delay in contacting an ambulance 26. Mr H tells us his wife was effectively left without a working catheter on 22 February. He said district nurses should have called an ambulance as soon as they experienced problems changing her catheter.
27. Mr H explains that had district nurses escalated his wife’s care as soon as they experienced problems, it may have avoided her development of urosepsis and her sad death.
28. The Trust says district nurses changed Mrs H’s catheter when it appeared blocked and contacted an ambulance when they felt her condition was deteriorating.
29. The NMC is the independent regulator of nurses in the UK. NMC code guidance sets out how nurses can provide good care.
30. Section 13.2 of NMC code guidance says nurses must make a timely referral to another practitioner when any action, care or treatment is required.
31. We can see district nurses visited Mrs H’s home on several occasions on 22 February. The first attendance at 10.45am appears to be a routine six weekly catheter change.
32. Those further visits at 12.50pm and 8.15pm were due to Mr H’s concerns that his wife’s catheter was not functioning correctly.
33. Our detailed investigation considered both Mrs H’s district nursing records and her hospital records.
34. In reviewing both sets of records our nephrologist adviser told us Mrs H may have been suffering from an infection and an AKI before her admission to hospital.
35. Mrs H’s blood results upon admission to hospital indicate she was suffering from an AKI, and we can see doctors diagnosed AKI alongside urosepsis accordingly. An AKI can cause a reduction in urine output.
36. We understand Mr H is concerned his wife was suffering from urinary retention due to a faulty catheter and this could be a contributing factor to her development of urosepsis.
37. We are not convinced Mrs H was suffering from urinary retention.
38. This is because urologists changed her catheter to rule out the possibility of a blockage following her hospital admission. They did not record a significant amount of urine following this change.
39. Our nephrologist adviser and our nursing adviser said there is some evidence to suggest the catheter may have been working correctly during the initial district nurse visit at 10.45am as they can see the district nurse noted ‘urine seen in the tube’.
40. This means urine may have been passing correctly from Mrs H’s bladder into the catheter. Unfortunately, the district nursing records lack detail, so we are unable to more accurately verify this.
41. Mrs H’s hospital records note that she had a suprapubic urine sample taken by her GP Practice on 14 February (prior to the events we are investigating) which came back positive for coliform bacillus.
42. A suprapubic urine sample is collected from the urinary catheter its tubing or the bag. Coliform bacillus is a type of bacteria commonly found in the intestinal tract.
43. There is no further information in Mrs H’s hospital records to better understand why the GP practice sent the sample to the hospital or what action Mrs H’s GP took at the time.
44. A positive urine culture from a catheter specimen does not always require treatment and will depend upon whether the patient is clinically unwell at the time.
45. Having said this, we think it is important to evidence in our final report that Mrs H had a positive urine culture around a week before the events set out in this complaint.
46. Our nephrologist adviser said if we consider this alongside the other evidence we have described above, it suggests Mrs H was suffering from a low-level and hard to spot infection. This infection may have been present to some degree a week before the events we are investigating.
47. We see the infection alongside the AKI impacted Mrs H’s ability to produce urine.
48. This could explain why there was still very little urine showing in Mrs H’s catheter even after repeated catheter changes both in the community and following her admission to hospital.
49. We think the lack of urine reaching Mrs H’s catheter during this period was most likely the result of the low-level infection and AKI rather than a blocked catheter or any mismanagement of this equipment.
50. We do not see district nurses’ management of Mrs H’s catheter is likely to have caused or contributed to the development of urosepsis.
51. In discussing this with our nephrologist adviser we think the low-level infection Mrs H was likely suffering from alongside the AKI are more likely to be the driving factors behind her development of this condition.
52. Mrs H’s infection and her AKI would have been difficult to spot prior to her hospital admission. Both our nursing adviser and our nephrologist adviser found no clear signs of this infection during the earlier stages of her community care on 22 February.
53. We therefore do not see district nurses should have escalated her care before clear signs of illness were discovered at around 8.15pm on 22 February.
54. Once it became clear Mrs H was unwell, district nurses promptly escalated her care in line with NMC code guidance.
Hospital staff did not explain what was wrong with Mrs H 55. Mr H tells us medical staff did not explain what was wrong with his wife and a doctor did not answer his questions. He said this lack of communication was upsetting and distressing.
56. The Trust acknowledged its staff did not thoroughly explain what was wrong with Mrs H and that some of its staff did not answer his questions. It offered apology during the complaints process.
57. Our Principles say public bodies should communicate effectively, using clear language that people can understand and that is appropriate to them and their circumstances.
58. We can see some evidence to indicate medical staff did update Mr H at the earlier stages of his wife’s hospital admission.
59. For example, we can see medical staff explained the seriousness of his wife’s condition on 23 February. Mr H appears to have agreed a do not attempt cardiopulmonary resuscitation (DNACPR) with staff during this same discussion.
60. A DNACPR means that medical staff will not attempt cardiopulmonary resuscitation (CPR) if the patient’s heart stops beating.
61. We can also see a palliative nurse spoke with Mr H that same day to reiterate the seriousness of his wife’s condition and talk about where she would like to be cared for if she continued to deteriorate.
62. On 24 February it appears Mrs H’s condition improved, and it was only in the last few days of her admission that she deteriorated again and sadly died.
63. We considered the medical records from the 24 February onward to get a better understanding of whether medical staff updated Mr H of his wife’s condition.
64. We can see a nursing entry dated 25 February. The nurse appears to have made ‘family’ aware that Mrs H was still unwell and that she needed ongoing intravenous antibiotics.
65. The next day on 26 February we can see a doctor informed Mrs H’s daughter that her mother was ‘still very poorly’.
66. On 2 March a doctor informed Mr H that his wife’s recovery was, ‘probably going to be very protracted.’
67. At 9.45am on 3 March, Mrs H appears to have deteriorated, and doctors reported she was agonal breathing.
68. Agonal breathing is usually characterised by gasping breaths and is typically experienced at the end of someone’s life when they are about to die. Ten minutes later, we can see a doctor reviewed Mrs H and reported she had sadly died.
69. Following Mrs H’s death at 10.08am, we can see a doctor completed some paperwork to confirm her death and noted: ‘For mortality paperwork, I do not feel this death was unexpected. From seeing this lady's condition on arrival to the ward yesterday morning and observation from across the bay, I thought that there was a high chance she was not going to survive this admission. I had incorrectly assumed that her husband was aware of this, by his constant presence by her side, but it appears that in fact that was just due to his utter devotion to her and he was not aware how unwell she was.’
70. The above quotation appears to sum up what we have seen in the records. While clinical staff appear to have told Mr H or other family members that Mrs H was unwell in the latter stage of her admission, there is no evidence clinical staff gave any detail about what was wrong with her.
71. There appears to have been a general assumption that because Mr H was present at his wife’s bedside throughout, he must therefore have known about his wife’s condition. We view this as a failing as this is not in line with our Principles.
72. We are also persuaded by Mr H’s account that a doctor did not answer his questions. We believe he most likely did ask for updates from the doctor and did not receive a response. We also consider this to be a failing as it is not in line with our principles.
73. We reached this view because Mr H is reported to have been at his wife’s bedside throughout the period we are investigating and took an active role in his wife’s care. We therefore think it is most probable that Mr H did ask medical staff, most likely a doctor according to his account, about his wife’s condition but did not get an answer.
74. We will consider what impact this had upon Mr H in the next section of this final report where we will also consider what remedy will put it right.
Impact 75. We see medical staff failed to keep Mr H updated of his wife’s condition.
76. Mr H will already have been very worried about his wife following discussions with medical staff earlier in her admission.
77. After 24 February, there is reference to medical staff informing Mr H or other family members that Mrs H was very ill, but there is nothing to suggest those medical staff gave any detail about what was wrong with her.
78. This lack of information likely led to some avoidable upset and distress. This view appears to be supported by the doctor’s note we described at paragraph 69 of this final report.
79. This upset and distress will primarily have taken place between 24 February and 3 March.
80. We therefore consider Mr H to be at level two on our severity of injustice scale, and we are likely to award a financial remedy in line with this. Our severity of injustice scale consists of six levels of injustice with increasing severity.
81. The next section of our report will set out what financial remedy we recommend.
82. Mr H also wants the Trust to acknowledge its errors, apologise for them and make service improvements.
83. Having carefully considered the Trust’s remedial action during the complaints process, we are satisfied its acknowledgement of what went wrong, and its apology are sufficient and in line with our Principles for Remedy.
84. The Trust also told us it had already put in place improvements in how it communicates with patients, family members and carers.
85. We acknowledge these events took place around four years ago, so it is understandable that the Trust may have already put in place some service improvements during this time.
86. The Trust supplied our Office with evidence that it implemented a ‘daily communication standard’ (the standard) in 2025. The standard sets out what good communication with patients and carers looks like. We understand the Trust communicated it to staff through a variety of education and training sessions.
87. Having reviewed this standard, we can see it includes a key improvement which we see directly addresses the failing identified in this final report.
88. The standard requires individual clinical staff, or multi-disciplinary team (MDT) members to communicate key details to the patient, their family or carer on a daily basis. These key points include, for example, diagnosis and checking the patient’s understanding of it, treatment plans, likely length of treatment and daily goals.
89. While we recognise this is something we would normally expect to see, we are pleased the Trust has formalised it into the standard and makes it a daily occurrence.
90. This sits alongside other improvements like training and staff events, for example, which the Trust has also described. We think these improvements and their regularity will be instrumental in ensuring patients, their families and carers are given the right level of information at the right time.
91. Having carefully considered the remedial action the Trust has already undertaken, we are satisfied it is sufficient and in line with our Principles for Remedy.