Source · Prevention of Future Deaths

George Richardson

Ref: 2015-0189 Date: 15 May 2015 Coroner: Derek Winter Area: Sunderland Responses identified: 1 / 1 View PDF

Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.

Date 15 May 2015
56-day deadline 10 Jul 2015 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.
View full coroner's concerns
_ Catheterisation was carried out including attemptslmanipulation on several occasions by different individuals without recourse to a consolidated catheterisation record , Individuals were not always aware of_previous catheter challenges s0 as to promote the involvement ofa Civic Centre; Burdon Road Sunderland, SRZ 7DN Tel 0191 5617843 Fax 0191 5537803 DX 60729 Sunderland WWw sunderland gov uklcoroner City Artery

Urologist: The Trust are addressing their Catheterisation but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set

Responses

1 respondent
Department of Health Central Government
9 Jun 2015 PDF
Noted

The Department of Health acknowledges the concerns, highlights existing national guidance on catheterisation from NICE and RCN, and states that ensuring staff are aware of guidance and how to seek help is for hospital trusts to action locally. (AI summary)

View full response
Fonn Ben Gummer Pariamentary Under Secefary Of State fo: Care Quahty Department of Health Richmond House 79 Whiteham POCS 935695 London SWAZNS To: Derek Winter HM Senior Coroner for the of Sunderland Civic Centre 2 9 Jun 2015 Burdon Road tadt Sunderland Ctv SR2 7DN 0 2 :"W pt lnfkr Thank you for your letter to the Secretary of State about the death of George Richardson. I am responding as the Minister with responsibility for service quality at the Department of Health. Iwas sorry very to hear of Mr Richardson'$ death and would be grateful if you would pass on my condolences to his family: Your report details and #nacceptable failure in patient care at Sunderland Royal Hospital and asked whether there was a need for national guidance 0 catheterisation; given the number of these procedures carried out within the NHS each year: NHS England (NHSE) confirms that there are, at present; two sources ofnational guidance in the UK:
1. National Institute for Health and Care Excellence guidance focussed on prevention of infection related to urethral catheters, which can be found at: https:ILwwwnice Org uklguidancelgs6] /chapter/quality-statement-4-urinary cathetersttsource-guidance-4: 2 The Royal College of Nursing (RCN) guidance 'Catheter Care RCN guidance for Nurses which can be found at: https:| www rcn org ukl data/assets pdf_file/0018/157410/003237 pdf The RCN publication aims to encourage further adoption of the National Occupational Standards (which describe best practice by bringing together skills, knowledge and values ; across all NHS and independent health care sectors. National Occupational Standards may also be used as benchmarks for qualifications. MP City 70'5 ine

The guidance includes a suggested structure for gaining competence in catheterisation; including comprehensive section on the importance of accurate documentation; which is clearly relevant to Mr Richardson's case. We understand the British Association of Urological Nurses (BAUN) has chosen not to develop separate national guideline on catheterisation to avoid duplication and Potential confusion with both the RCN publication and the European Association of Urology Nurses (EAUN) guidance relating to all aspects of catheter care, published in
2012. The EAUN guidelines, entitled 'Evidence-based Guidelines for Best Practice in Urological Health Care Catheterisation, Indwelling catheters in adults Urethral and Suprapubic' can be found at wwwbaun CO_uklindex php/download_filelview/304/226L While neither of these publications advise on the number of attempts at re- catheterisation prior to seeking specialist assistance from a urologist or urology nurse specialist; it is generally to be expected that senior/ specialist assistance should be sought when a clinician finds difficulty in any procedure. The British Association of Urological Surgeons (BAUS) has advised that the issue of when and how to seek more senior help following repeated failed attempts at catheterisation is best managed by local, rather than national, guidance Appropriate national guidance already exists. Ensuring staff know of it,and how and when to seek help where catheterisation proves problematic, is for hospital Trusts to action locally For the future, should BAUS determine a need for further national advice, NHS England would support its dissemination: Ihave also passed your repprt to Anne Bishop, Chief Executive of BAUS, and to Fiona Sexton, the Presidert of BAUN, who have been asked to write to you on this issue. Thank you for brirging this matter to our attention BEN GUMMER

Report sections

Investigation and inquest
On 12th February 2015 commenced an investigation into the death of George Richardson, aged
84. The investigation concluded at the end of the Inquest on 12th May 2015. The conclusion of the Inquest was a Natural occurring heart condition contributed to by complications from catheterisation"
Circumstances of the death
George Richardson died in Sunderland Royal Hospital on 9th February 2015 at 05.10 hours having been admitted on 2Oth January 2015_ He went into urinary retention and required catheterisation on several occasions by different individuals during which time he suffered urethral trauma_ The cause of death following the Post Mortem Examination was: Ia Ischaemic Heart Disease; Ib Coronary Atheroma; II Traumatic Urethral Catheterisation and Infective Exacerbation Of Chronic Obstructive Pulmonary Disease _
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

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Report details

Reference
2015-0189
Date of report
15 May 2015
Coroner
Derek Winter
Coroner area
Sunderland

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Jul 2015 (estimated).

Sent to

Department of Health and Social Care

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