Swansea Bay University Health Board

Mrs C complained about the care provided to her husband, Mr C, by Swansea Bay University Health Board (‘the Health Board’) when he was an inpatient at Morriston Hospital. Specifically, whether Mr C’s catheter was appropriately managed between September and December 2022.

The Ombudsman found that, although many aspects of Mr C’s catheter care and management were appropriate, there were instances of shortfalls in the documentation, monitoring and management of Mr C’s catheter between September and December 2022 that could have contributed to increasing the risk of urinary tract infections (‘UTIs’). This service failure was an injustice to Mr C. The Ombudsman therefore upheld the complaint.

The Health Board agreed to the Ombudsman’s recommendations; to provide a written apology to Mr and Mrs C for the failings identified; to develop and implement a Fluid Balance and Hydration procedure and an audit process to ensure adherence to procedure, if not already available; to implement an audit process of catheter related and fluid balance related annual training, to monitor completion; to develop and implement a catheter valve patient assessment process, to ensure patient competence assessment can be more robustly demonstrated, and; to implement an Internal Safety Alert and targeted education on urinary catheter clamping, to reiterate the Health Board’s Policy.