Recurring concern

Unsafe catheterisation practice

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First reported 29 Apr 2014•Latest report 26 Sep 2017

Definition

What this concern includes

Includes failures of controls dedicated to safe catheterisation, including standards, competence and training, access to relevant prior catheterisation information, recognition of difficulty, escalation, specialist involvement and performance of catheterisation where these deficiencies create unsafe practice.

Not included

Excludes generic clinical training, documentation or information-sharing deficiencies that are not specifically tied to catheterisation safety.
Excludes failures involving urinary monitoring, fluid balance or the decision to catheterise when catheterisation practice itself is not deficient.
Excludes unrelated procedures, including other invasive interventions, unless the assertion explicitly concerns catheterisation.
Excludes the underlying patient condition or outcome without an identified failure of a catheterisation safety control.

Reports: 3
Individual concerns: 5
Date range: 2014–2017
Stated actions: 3

Reports 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.

Department of Health and Social Care2

Swansea Bay University Local Health Board1

Torbay Hospital1

Ty Nant Nursing Home1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

26 Sep2017
South Wales Central
Concerns raised1
1. Lack of training in male catheterisation
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Maintain a central electronic booking and attendance diary for community catheterisation training.
  Stated by Swansea Bay University Local Health BoardStated completed
2. Action
  Assign community catheterisation training to the Community Continence Service and secondary-care training to secondary care.
  Stated by Swansea Bay University Local Health BoardStated planned
3. Action
  Share catheterisation training dates with the Long Term Care Team to monitor attendance by care home and identify non-participating homes for closer monitoring.
  Stated by Swansea Bay University Local Health BoardStated planned
AI-generated summary

Hedley Greenland · 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

Hedley Greenland, who was residing in a nursing home and had prostate cancer requiring permanent catheterisation, became acutely unwell on 17 December 2016 and died in hospital on 20 December 2016. The inquest concluded that he died from the effects of a urine infection in circumstances where fluid input and catheter output were not adequately monitored for over nine hours. Concerns included the absence of fluid balance monitoring and written handover, inadequate catheter-care training and knowledge, and the absence of evidence that the Catheter Care Bundle was being used.

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
Lack of training in male catheterisation
Wider context from the report
“(2) The qualified nurse on duty overnight 16th/17th December was not trained in male catheterisation. ”
Source location
Hedley Greenland · 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
Maintain a central electronic booking and attendance diary for community catheterisation training.

Verbatim wording from the response
“Since this incident a review has been undertaken. The Health Board have now implemented a booking and attendance system at community training which is to be recorded using an electronic central booking diary. This will ensure that accurate records are maintained of those who have attended training. It will also highlight areas where staff have not attended training.”

Source location
2017-0235-Response
Page 1 · response
Published 2 October 2017
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
Assign community catheterisation training to the Community Continence Service and secondary-care training to secondary care.

Verbatim wording from the response
“Furthermore, where training for catheterisation was shared previously between all Continence Assessors, the Community Continence Service will now take responsibility for training community staff and secondary care will train staff in the secondary care setting.”

Source location
2017-0235-Response
Page 1 · response
Published 2 October 2017
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
Share catheterisation training dates with the Long Term Care Team to monitor attendance by care home and identify non-participating homes for closer monitoring.

Verbatim wording from the response
“Training dates for catheterisation have been shared with Long Term Care Team to ensure the Health Board are able to monitor attendance from each care home. The Long Term Care Team work in partnership with Local Authority to monitor standards within the care home setting, part of this process is to review each care homes training register. Care homes that are not participating in training will be identified and monitored closely to improve compliance.”

Source location
2017-0235-Response
Page 2 · response
Published 2 October 2017
Open published response
15 May2015
Sunderland
Concerns raised3
1. Lack of a consolidated catheterisation record
2. Failure to recognise previous catheterisation challenges and promote Urologist involvement
3. Lack of national standards for safe and effective catheterisation skills
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 3
1. Position
  Hospital Trusts are responsible for locally ensuring staff know the guidance and when to seek specialist help during difficult catheterisation.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  BAUS considers decisions about seeking senior help after repeated failed catheterisation attempts best addressed through local rather than national guidance.
  Stated by Department of Health and Social CareRedirects responsibility
2. Position
  Existing national catheterisation guidance is considered sufficient, so additional national guidance is not currently required.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

George Richardson · 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

George Richardson died in Sunderland Royal Hospital on 9 February 2015 after admission for urinary retention, during which he underwent several catheterisation procedures and suffered urethral trauma. The report raised concerns about repeated catheterisation by different individuals without a consolidated catheterisation record, meaning staff were not always aware of previous difficulties or prompted to involve a urologist.

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
Lack of a consolidated catheterisation record
Wider context from the report
“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record. Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist. The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set. ”
Source location
George Richardson · 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 recognise previous catheterisation challenges and promote Urologist involvement
Wider context from the report
“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record. Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist. The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set. ”
Source location
George Richardson · 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
Lack of national standards for safe and effective catheterisation skills
Wider context from the report
“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record. Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist. The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set. ”
Source location
George Richardson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
Hospital Trusts are responsible for locally ensuring staff know the guidance and when to seek specialist help during difficult catheterisation.

Verbatim wording from the response
“Appropriate national guidance already exists. Ensuring staff know of it, and how and when to seek help where catheterisation proves problematic, is for hospital Trusts to action locally. For the future, should BAUS determine a need for further national advice, NHS England would support its dissemination.”

Source location
2015-0189-Response-by-Department-of-Health
Page 2 · response
Published 15 May 2015
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
BAUS considers decisions about seeking senior help after repeated failed catheterisation attempts best addressed through local rather than national guidance.

Verbatim wording from the response
“The British Association of Urological Surgeons (BAUS) has advised that the issue of when and how to seek more senior help following repeated failed attempts at catheterisation is best managed by local, rather than national, guidance.”

Source location
2015-0189-Response-by-Department-of-Health
Page 2 · response
Published 15 May 2015
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 national catheterisation guidance is considered sufficient, so additional national guidance is not currently required.

Verbatim wording from the response
“Appropriate national guidance already exists. Ensuring staff know of it, and how and when to seek help where catheterisation proves problematic, is for hospital Trusts to action locally. For the future, should BAUS determine a need for further national advice, NHS England would support its dissemination.”

Source location
2015-0189-Response-by-Department-of-Health
Page 2 · response
Published 15 May 2015
Open published response
29 Apr2014
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to limit catheterisation frequency
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stephen Anthony Allardice Widman · 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

Stephen Anthony Allardice Widman had a history of rectal carcinoma and was repeatedly catheterised. An inappropriately placed catheter was considered likely, infection developed, and he became weakened by pneumonia before dying from sepsis associated with a urinary tract infection and pyelonephritis. Concerns included delays in treating neutropenic sepsis in Accident and Emergency and frequent catheterisation without urological management.

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
Failure to limit catheterisation frequency
Wider context from the report
“1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department. 2. The deceased was catheterised too frequently without the management of a urologist. Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number. ”
Source location
Stephen Anthony Allardice Widman · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of training in male catheterisation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised3

Lack of a consolidated catheterisation record

Failure to recognise previous catheterisation challenges and promote Urologist involvement

Lack of national standards for safe and effective catheterisation skills

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to limit catheterisation frequency

Actions described in response 3

Respondent positions 3