Recurring concern

Unreliable availability of urinary catheters for required care

First to latest report 20 Aug 2013 — 28 Jan 2022

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 5

What this concern includes

Includes failures of controls dedicated to supplying, stocking, ordering, locating or maintaining the availability of urinary catheters, including suprapubic and sterile replacement catheters, when the deficiency can delay or prevent required care.

What is not included

Excludes catheter insertion, replacement technique, drainage, flushing, removal and trial-without-catheter management when catheter availability is not the deficient control.
Excludes generic equipment or medical-supply shortages unless urinary-catheter availability is specifically identified.
Excludes failures to monitor or treat complications after a suitable catheter has been made available.
Excludes generic ordering, stock-control or management deficiencies that do not concern urinary catheters.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Chief Medical Officer for England and Wales1

Copperfields1

Department of Health and Social Care1

Exemplar Health Care Services Limited1

Pennine Acute Hospitals NHS Trust1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

28 Jan2022
West Yorkshire Eastern
Concerns raised2
1. Unavailability of sterile replacement catheters in stock
2. Failure to detect mistakes in ordering replacement catheters
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Exemplar Health Care
Stated actions 4
1. Exemplar Health Care
  Update the catheter policy to require sufficient stocks for planned, unplanned and emergency catheter changes.
2. Exemplar Health Care
  Implement layered catheter-stock controls, including weekly checks, resident-level supplies, minimum backup stocks, daily records and handover sign-off.
3. Exemplar Health Care
  Implement EMAR stock visibility, low-stock alerts and daily or weekly dashboard monitoring with remote clinical oversight.
1. Exemplar Health Care
  Provide EMAR training to staff and access to continuous EMAR support and an out-of-hours management contact system.
Respondent positions 2
1. Exemplar Health Care
  The catheter stock failure was an isolated communication error, with no evidence of similar incidents occurring before or since.
  Disputes the concern
1. Exemplar Health Care
  Existing electronic, visual and dashboard stock controls remove the risk of communication errors causing catheter shortages.
  Existing arrangements considered sufficient
AI-generated summary

Mark Anthony Athias · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mark Anthony Athias had multiple physical and mental health issues, including recurring urinary infections and problems with a long-term catheter. After difficulties with his catheter on 2 July 2021, he was admitted to hospital, where his condition deteriorated and he died on 6 July 2021. Concerns included a lack of sterile replacement catheters, inadequate monitoring records, and a missing handover record, with risks arising from deficient record keeping.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of sterile replacement catheters in stock
Wider context from the report
“1. The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr Athias had difficulties with his catheter, which had necessitated it being replaced twice in previous weeks. The mistakes made in ordering replacements had not been detected by the managers in the nursing home. ”
Source location
Mark Anthony Athias · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to detect mistakes in ordering replacement catheters
Wider context from the report
“1. The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr Athias had difficulties with his catheter, which had necessitated it being replaced twice in previous weeks. The mistakes made in ordering replacements had not been detected by the managers in the nursing home. ”
Source location
Mark Anthony Athias · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the catheter policy to require sufficient stocks for planned, unplanned and emergency catheter changes.

Verbatim wording from the response
“You heard evidence from ████████, Head of Quality for Exemplar Health Care Services that following Mr Athias' death Exemplar Health Care's catheter policy was updated to reflect the importance of retaining sufficient stocks of catheters in all Exemplar Health Care homes. You were provided with a copy of the updated policy and your attention was drawn to the following paragraph:”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 1 · response
Published 31 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement layered catheter-stock controls, including weekly checks, resident-level supplies, minimum backup stocks, daily records and handover sign-off.

Verbatim wording from the response
“You were provided with written evidence from Nurse ████████ that she recognised that the catheter stock was insufficient during an out of hours shift on 2 July 2021, and she requested that further catheters be ordered. Unfortunately, due to a communication error this request was not actioned. ████████ explained that, following Mr Athias' death, she personally reviewed all incidents across the Exemplar Health Care organisation and found no evidence of a similar incident occurring, either before or since. She explained that the lack of sterile catheter was therefore an unfortunate, one-off communication error. Ms ████████ also explained that, shortly after Mr Athias' death, weekly stock checks were implemented at Copperfields in order to ensure a sufficient level of stock is maintained at all times. This new system is working well.”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement EMAR stock visibility, low-stock alerts and daily or weekly dashboard monitoring with remote clinical oversight.

Verbatim wording from the response
“Following Mr Athias' death, Exemplar Health Care has also implemented an Electronic Medication System ("EMAR"). This means that stock level is visible on the EMAR system at all times and stock levels can be viewed by the nurses on EMAR laptops, and remotely by Clinical Nurse Managers, Heads of Care, the Registered Home Managers and the central support service 24 hours a day. This has resulted in far more overview of stock at all levels of seniority and removes the risk of a communication error leading to an absence of equipment such as occurred in Mr Athias' case.”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide EMAR training to staff and access to continuous EMAR support and an out-of-hours management contact system.

Verbatim wording from the response
“Copperfields delivered shared learning with the nursing staff following Mr Athias' death which highlighted the other avenues available to access catheters in the community. In addition, following the implementation of the EMAR system at Copperfields in February 2022, all staff were provided with several weeks of EMAR training and have access to 24 hours a day support from the EMAR team. The nurses and management team have been trained to review the stock”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The catheter stock failure was an isolated communication error, with no evidence of similar incidents occurring before or since.

Verbatim wording from the response
“You were provided with written evidence from Nurse ████████ that she recognised that the catheter stock was insufficient during an out of hours shift on 2 July 2021, and she requested that further catheters be ordered. Unfortunately, due to a communication error this request was not actioned. ████████ explained that, following Mr Athias' death, she personally reviewed all incidents across the Exemplar Health Care organisation and found no evidence of a similar incident occurring, either before or since. She explained that the lack of sterile catheter was therefore an unfortunate, one-off communication error. Ms ████████ also explained that, shortly after Mr Athias' death, weekly stock checks were implemented at Copperfields in order to ensure a sufficient level of stock is maintained at all times. This new system is working well.”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing electronic, visual and dashboard stock controls remove the risk of communication errors causing catheter shortages.

Verbatim wording from the response
“Following Mr Athias' death, Exemplar Health Care has also implemented an Electronic Medication System ("EMAR"). This means that stock level is visible on the EMAR system at all times and stock levels can be viewed by the nurses on EMAR laptops, and remotely by Clinical Nurse Managers, Heads of Care, the Registered Home Managers and the central support service 24 hours a day. This has resulted in far more overview of stock at all levels of seniority and removes the risk of a communication error leading to an absence of equipment such as occurred in Mr Athias' case.”

Source location
2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022
Open published response
20 Aug2013
Manchester North
Concerns raised1
1. Difficulties in locating suprapubic catheters before procedures
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Pennine Acute Hospitals NHS Trust
Stated actions 1
1. Pennine Acute Hospitals NHS Trust
  Label, regularly check and appropriately store suprapubic catheter procedure trays.
Respondent positions 2
1. Pennine Acute Hospitals NHS Trust
  Procedure trays are clearly labelled, regularly checked and appropriately stored, so no change to tray arrangements is identified.
  Existing arrangements considered sufficient
1. Pennine Acute Hospitals NHS Trust
  The difficulty locating the procedure kit resulted from individual unfamiliarity, not inadequate tray labelling, checking or storage.
  Disputes the concern
AI-generated summary

Derek BRIERLEY · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Derek Brierley’s urethral catheter became blocked and attempts to recatheterise him were unsuccessful, including an abandoned suprapubic catheter insertion, after which he became acutely unwell with features of peritonitis. Concerns included the likely high insertion site, the absence of Trust guidelines on competence and training for the procedure, and difficulties locating a suprapubic catheter beforehand.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Difficulties in locating suprapubic catheters before procedures
Wider context from the report
“3)Difficulties were encountered in locating a suprapubic catheter prior to the procedure ”
Source location
Derek BRIERLEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Label, regularly check and appropriately store suprapubic catheter procedure trays.

Verbatim wording from the response
“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.”

Source location
2013-0244-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Page 2 · response
Published 30 December 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Procedure trays are clearly labelled, regularly checked and appropriately stored, so no change to tray arrangements is identified.

Verbatim wording from the response
“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.”

Source location
2013-0244-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Page 2 · response
Published 30 December 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The difficulty locating the procedure kit resulted from individual unfamiliarity, not inadequate tray labelling, checking or storage.

Verbatim wording from the response
“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.”

Source location
2013-0244-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Page 2 · response
Published 30 December 2013
Open published response