County Durham and Darlington NHS Foundation Trust

3. Mrs L complains that STEES delayed changing Mr L’s urethral catheter after July 2023.

4. Mrs L complains that CDDFT did not conduct sufficient observations of Mr L on the day he died.

5. Mrs L says because of STEES delaying changing Mr L’s urethral catheter he missed the opportunity to have chemotherapy and died prematurely in hospital rather than at home.

6. Mrs L says because of CDDFT not conducting sufficient observations she was not able to be with Mr L when he died, and she does not know what happened to him in the last couple of hours of his life.

7. Mrs L would like a financial remedy and service improvements.

8. Mr L was diagnosed with incurable bladder cancer in January 2023 and began receiving palliative chemotherapy in May 2023. This is cancer treatment to improve the quality of someone’s life.

9. Both of Mr L’s kidneys were blocked so STEES inserted a ureteric stent. This is a thin, flexible tube inserted into the ureter (tube that transports urine from the kidneys to the bladder) to allow urine to drain from the kidney to the bladder. Mr L’s bladder was not fully emptying so STEES also inserted a urethral catheter. This is a flexible tube to empty the bladder and collect urine into a drainage bag.

10. Due to continued swelling in his right kidney, in April 2023 STEES inserted a nephrostomy into Mr L’s right kidney. A nephrostomy tube is inserted directly into the kidney to further support draining urine. This was because his internal ureteric stent was not working adequately.

11. Between December 2023 and April 2024 CDDFT admitted Mr L to hospital several times due to urinary sepsis. Sepsis is a serious condition where the body’s response to an infection causes injury to its own tissues and organs. The type of sepsis Mr L had come from a urinary tract infection.

12. In February 2024 STEES decided further palliative chemotherapy would not be in Mr L’s best interests because he was unwell and had experienced multiple infections needing hospital admissions.

13. Sadly, Mr L died in hospital in April 2024. A coroner is someone whose role is to find out how and why someone died. A coroner reviewed Mr L’s death. They concluded he died due to urinary sepsis ‘secondary to’ (that is related to, or caused by) his cancer.

Catheter

17. Mrs L complains that STEES’ delay in changing Mr L’s catheter after July 2023 meant he missed the opportunity to have chemotherapy and died prematurely in hospital rather than at home. She thinks if STEES had changed his catheter earlier, he would not have developed urinary sepsis and he would have been able to have further chemotherapy.

18. STEES acknowledges it should have changed Mr L’s catheter in September 2023, at the same time as his ureteric stent. It did not change it until December 2023. It explained this happened because of an oversight caused by human error. STEES has provided feedback to staff to ensure such miscommunication about when catheters should be changed does not occur again.

19.STEES said it was not possible to determine if the delay caused Mr L’s infections. It said even if it did play a part, it would have been only one of several contributing factors. We acknowledge how difficult it is for Mrs L to be left believing her husband lost the chance to have more time to prepare and to be at home with her before he died. We understand why this concern is so important to Mrs L and we have considered whether we can say anything more about the impact of STEES’ mistake.

20.We think it is important to note that Mr L did not develop urinary sepsis during the period the catheter change was delayed.

21.Mr L’s first episode of urinary sepsis in December 2023 occurred after the catheter change, rather than during the period of delay. After the catheter change, he then experienced multiple hospital admissions for sepsis before his death in April. This makes it difficult to establish a link between the timing of the catheter change and the infections.

22.There are several other possible explanations for why Mr L developed sepsis. Cancer Research UK explains that chemotherapy can weaken the immune system, leaving patients more vulnerable to infection. As Mr L had had chemotherapy his would have placed Mr L at a higher risk of infection.

23.He also had a nephrostomy, which itself carries a risk of infection.

24.In addition, we note that changing or removing a catheter can disturb bacteria and sometimes trigger infection or sepsis, even when it is done correctly and on time.

25.We are also aware that the coroner did not find that the delay in catheter change caused or contributed to Mr L’s death, but rather that his sepsis was related to his cancer.

26.Our adviser’s view on this, which we share, is that it is unlikely the delay in changing Mr L’s catheter caused his infection or led to his death. The evidence suggests there were several other possible explanations for why he developed sepsis, which appear just as likely, or more likely, based on the information available.

27.We hope Mrs L will be reassured by our view. We acknowledge that Mr L did not get the standard of care he had the right to expect (his catheter should have been changed sooner) and the delay did have the potential to contribute to him acquiring infections. However, for the reasons we have explained above we do not think the available evidence indicates that the delay in changing the catheter caused Mr L’s sepsis, prevented further chemotherapy or caused his death.

28.We recognise how upsetting it is for Mrs L that her husband did not receive the catheter care he should have received. Our decision is not intended in any way to detract from Mrs L’s concerns.

29.For the reasons discussed above, we do not propose to take further action with this part of Mrs L’s complaint.

Observations

19. We have also considered Mrs L’s complaint that CDDFT did not conduct sufficient observations of Mr L on the day he died.

20. NEWS guidelines explain that the NEWS is a hospital tool used to identify if a patient is becoming unwell by assessing their vital signs. These include their breathing rate, oxygen levels, temperature, blood pressure, pulse, and alertness. Each is scored based on how abnormal it is. The total score guides how often the patient should be monitored, how urgently they need care, and the level of clinician required.

21. NEWS guidelines recommend if the NEWS score is low (between one and four) staff should take the patient’s observations at least every four to six hours. They also recommend a nurse assess the patient to decide if their monitoring needs to be increased or if their care should be escalated to a doctor.

22. CDDFT observed Mr L at 5.33am and 11.02am on the morning of the day he died. CDDFT calculated his NEWS score as three on both occasions. Both observations should have triggered a review by a nurse and observations at least every six hours. We cannot see a nurse reviewed him at 5.33am or 11.02am but the nursing handover notes at 9.56am and 2.01pm do not record any issues with Mr L.

23. There are nursing review notes in the afternoon which say Mr L had pulled out his nasogastric tube. A nasogastric tube is a thin, flexible, plastic tube which is passed through someone’s nose down into their stomach. They can then be fed via this tube.

24. The nurse helped Mr L drink some Fortisip (a high energy drink) but he later vomited so the nurse had informed a doctor. The doctor reviewed Mr L and agreed to try letting Mr L go without a nasogastric tube that night.

25. The latest CDDFT should have carried out Mr L’s next observations was at 5.02pm but this did not happen indicating a failing to follow NEWS guidelines. The next records are from a healthcare professional who asked a nurse to check on Mr L. Mr L was unresponsive. They informed a doctor. When a doctor reviewed Mr L at 6.26pm sadly he had died.

26. Mrs L says because of CDDFT not conducting sufficient observations she was not able to be with Mr L when he died. She also says she does not know what happened to him in the last couple of hours of his life.

27. The records do not contain enough information for us to comment on whether any further information about Mr L’s condition would have been available after 5.02pm. We can only see indications that had CDDFT completed the observations by 5.02pm, Mrs L may have had more information about Mr L’s condition at that time.

28. Clear and timely information can help families feel informed and reassured, particularly about a loved one’s care in the lead up to their death. We appreciate CDDFT not completing the observations by 5.02pm has caused Mrs L avoidable distress at what is already a difficult time for her.

29. The NHS Complaint Standards require complaint handling to be thorough, fair, open and honest. They also set out the importance of learning from mistakes.

30. In response to her complaint CDDFT acknowledged it did not complete Mr L’s observations in the correct timeframe. It apologised that it did not identify Mr L’s deterioration sooner to allow Mrs L time to be with him. It has also given staff training on observations to reduce the likelihood of this issue happening again.

31. We asked the Trust for further information about its reflection on this aspect of Mrs L’s complaint. It told us it has provided Trust-wide training on recording and escalating patient observations. It also explained that most recently the Trust’s acute intervention team has given training on observations at the end of 2025 and the beginning of 2026.

32. To monitor the impact of this the Trust conducts monthly checks on the wards including confirming that:

• patients’ observations are up to date, and • staff understand how to escalate concerns regarding patient deterioration.

33. The Trust provides real-time feedback from these audits. If during the audit a patient’s observations are due, staff are asked to complete the required observations immediately. Wards are also required to create action plans after each audit to help managers identify any themes and to help them decide what further action needs to be taken.

34. We are satisfied the steps the Trust has already taken are fair and proportionate. While we recognise the impact this situation has had, we do not consider that a financial remedy would be appropriate on this occasion. We do not propose to take further action on Mrs L’s complaint.

35. We recognise that raising these concerns will not have been easy for Mrs L. We are grateful to her for taking the time to bring her complaint to us. Doing so not only ensures that her experience has been highlighted but also contributes to improving care for others.

1. We are very sorry to hear about Mr L’s death. We recognise how devastating this has been for Mrs L.

2. We have carefully considered Mrs L’s complaint about the actions of STEES and CDDFT. We have not seen indications that STEES changing Mr L’s catheter earlier would have altered the course of his treatment or changed the outcome. CCDFT has acknowledged it did not conduct Mr L’s observations when it should have done, and we think it has already done enough to put right the impact of this.