The Pennine Acute Hospitals NHS Trust
NHS / Health Body
Action Taken
The hospital has re-drafted the pathway for managing urinary retention, shared it with A&E staff, initiated a training program for inserting catheters outside of the urology division, and will continue to monitor catheter-related incidents. (AI summary)
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Dear Mr Nelson Further to your Regulation 28 dated 30th September 2013 for events relating to the death of Mr Derek Brierley , can report that the following actions have been taken to prevent future deaths
1) The pathway for managing urinary retention has been re-drafted & supra-pubic aspiration is the first line intervention for those unable to insert supra-pubic catheters, followed by transfer to North Manchester Urology department or A&E. (Summary Pathway enclosed)
2) The pathway has been shared with A&E staff so that are aware of it (& had opportunity to comment on it).
3) The urology team have initiated a training program for those who may need to insert such catheters outside of the urology division. Individuals will need to be signed off for this, (a process we already use for chest drains). Those deemed competent include CT1 trainees & above for urology who have undergone the training, middle grade & above surgical trainees, other trainees at ST3 level & above who undergone the training:
5) Bladder scanning should be done before such procedures are attempted. (This was actually done in this particular case):
6). Such cases should be discussed with the urology team. (This was done in this particular case) -_ PLEASE NOTE THE TRUST HAS A SMOKE FREE ENVIRONMENT POLICY FOR STAFF, PATIENTS AND VISITORS: THIS INCLUDES BUILDINGS , GROUNDS AND CAR PARKS_ 202 2013 they they have
7) The governance lead for urology will continue to monitor catheter related incidents to ensure standards & processes are followed, but also ensure that adverse incidents are reported as clinical incidents.
8) Procedure trays are clearly labelled, regularly checked & appropriately stored: Difficulty finding the kit in this case was due to individual lack of familiarity as it is not a procedure frequently performed in a very busy A&E: believe that the above measures should ensure that this rare, but recognised complication of supra-pubic catheter insertion should not lead to a preventable death again.
1) The pathway for managing urinary retention has been re-drafted & supra-pubic aspiration is the first line intervention for those unable to insert supra-pubic catheters, followed by transfer to North Manchester Urology department or A&E. (Summary Pathway enclosed)
2) The pathway has been shared with A&E staff so that are aware of it (& had opportunity to comment on it).
3) The urology team have initiated a training program for those who may need to insert such catheters outside of the urology division. Individuals will need to be signed off for this, (a process we already use for chest drains). Those deemed competent include CT1 trainees & above for urology who have undergone the training, middle grade & above surgical trainees, other trainees at ST3 level & above who undergone the training:
5) Bladder scanning should be done before such procedures are attempted. (This was actually done in this particular case):
6). Such cases should be discussed with the urology team. (This was done in this particular case) -_ PLEASE NOTE THE TRUST HAS A SMOKE FREE ENVIRONMENT POLICY FOR STAFF, PATIENTS AND VISITORS: THIS INCLUDES BUILDINGS , GROUNDS AND CAR PARKS_ 202 2013 they they have
7) The governance lead for urology will continue to monitor catheter related incidents to ensure standards & processes are followed, but also ensure that adverse incidents are reported as clinical incidents.
8) Procedure trays are clearly labelled, regularly checked & appropriately stored: Difficulty finding the kit in this case was due to individual lack of familiarity as it is not a procedure frequently performed in a very busy A&E: believe that the above measures should ensure that this rare, but recognised complication of supra-pubic catheter insertion should not lead to a preventable death again.