Recurring concern
Unreliable management of urinary catheters
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Request correctionFirst reported 7 May 2015•Latest report 2 Apr 2026
What this concern includes
Includes failures in the dedicated management of indwelling or postoperative urinary catheters, including drainage configuration, flushing and monitoring, catheter-care bundles, duration and removal instructions, trials without catheter, postoperative guidance, staff training and escalation when catheter function or complications are abnormal.
Not included
- Excludes catheter insertion or general vascular-access procedures where ongoing urinary-catheter management is not the unsafe condition.
- Excludes failures involving chest drains, nasogastric tubes or other non-urinary drainage devices.
- Excludes generic fluid-balance monitoring, continence care or clinical-record failures unless they directly impair urinary-catheter management.
- Excludes medication, staffing or discharge failures that are not specifically part of the urinary-catheter management process.
- Reports
- 8
- Individual concerns
- 12
- Date range
- 2015–2026
- Stated actions
- 13
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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.
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Concerns raised1
Inadequate catheter management support
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Review and update catheter-care policies and procedures for safe, consistent practice.
Stated by Multi-Care Community Services Suffolk Ltd -
Action
Provide mandatory catheter-care training and competency assessment covering procedures, infection recognition, output monitoring, escalation and documentation.
Stated by Multi-Care Community Services Suffolk Ltd -
Action
Maintain regular catheter-care competency oversight through supervision, observational checks, refresher training, spot checks and monthly supervision.
Stated by Multi-Care Community Services Suffolk Ltd
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Concerns raised1
Failure to establish responsibility for catheter-care training
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The dispute between local authorities over catheter-care training and respite provision is for those local authorities to address.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised1
Failure to use specific language distinguishing catheter change from catheter care in requests
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.2
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Action
Highlight instructions for other clinical teams and send the original correspondence with onward referrals.
Stated by Lower Clapton Group Practice -
Action
Communicate the revised processes to the team and incorporate them into the induction programme.
Stated by Lower Clapton Group Practice
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Concerns raised2
Failure of the postoperative pathway to provide safe urinary catheter removal guidance
Lack of postoperative urinary catheter management instructions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.4
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Action
Revise the Enhanced Recovery Programme booklet to include post-operative urinary-catheter management guidance.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Print and roll out the amended Enhanced Recovery Programme booklets for use.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Add a pre-printed urinary-catheter prompt to daily ward-round sheets.
Stated by University Hospitals Sussex NHS Foundation Trust
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Action
Require documented medical instructions before nursing staff remove urinary catheters on surgical wards.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised3
Failure to prevent open-ended urinary catheters from draining freely
Lack of proper procedures for the safe care and management of urinary catheters
Failure to properly train relevant staff in urinary catheter care and management
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to flush indwelling catheters when required
Lack of understanding, knowledge and training in long-term indwelling catheter management
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.4
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Action
Maintain a central electronic booking and attendance diary for community catheterisation training.
Stated by Swansea Bay University Local Health Board -
Action
Assign community catheterisation training to the Community Continence Service and secondary-care training to secondary care.
Stated by Swansea Bay University Local Health Board -
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 Board
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Action
Train Health Board nursing-home assessors in urinary-catheter management and documentation, enabling practice measurement against agreed standards.
Stated by Swansea Bay University Local Health Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Care-home staff are not obliged to attend training, and attendance depends on providers releasing staff.
Stated by Swansea Bay University Local Health Board
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Position
Because of the region’s large care-home workforce, only general continence training can be offered to all staff.
Stated by Swansea Bay University Local Health Board
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Concerns raised1
Failure to manage trials without catheter safely
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to complete the daily catheter care bundle
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026