Source · SPSO (Scottish Public Services Ombudsman)

Fife NHS Board

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 201508301 Sector Health Category clinical treatment / diagnosis Decided 01 June 2016

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Full decision

Summary

Mr C complained that a district nurse had wrongly carried out a procedure to reinsert a catheter at home. The district nurse failed to reinsert the catheter three times and he had to be taken to hospital for the catheter to be reinserted. At hospital it was established that a false passage had been created during the attempts at catheterisation. The hospital successfully reinserted the catheter. Mr C felt that the district nurse had not followed protocols when attempting to reinsert the catheter.

We obtained independent advice on the case from a nurse adviser. She said that there were problems when the district nurse tried unsuccessfully to reinsert the catheter and that contact was made with Mr C's GP for advice. It was decided to arrange a non emergency ambulance to take Mr C to hospital for the catheter to be reinserted. The adviser said that Mr C had suffered a relatively rare but recognised complication of catheterisation and that this did not necessarily mean that there had been a failure in carrying out the procedure. It was also noted that attempts at catheterisation were made in the hospital, and therefore we could not be certain exactly when the problem arose. We did not uphold the complaint.

Related reading

View Decision Report 201508301 as a PDF (11.12 KB) Updated: March 13, 2018

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