3 Nov 2025 Brian Lloyd · Prevention of Future Deaths report North London
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Concerns raised 1 Failure to arrange prompt hospital transfer after two unsuccessful replacement catheter insertion attempts View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Distribute a quick-reference escalation flowchart to team leads.
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Action
Limit replacement-catheter insertion to two attempts, stop sooner for resistance, pain, or bleeding, and call 999 after two failures or earlier if sepsis is suspected.
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Action
Record each 999 call reference number and assign a staffed phone to respond promptly to emergency-service return calls.
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Action
Create and implement an escalation protocol.
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Action
Create and implement a full clinical protocol for catheterisation emergencies and escalation.
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Action
Provide face-to-face refresher training in catheterisation for all nurses and team leads.
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Action
Distribute a quick-reference catheterisation emergency poster to all nursing stations.
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Action
Review clinical documentation and escalation procedures to improve clarity and accountability.
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AI-generated summary
Brian Lloyd · 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
Brian Lloyd died in hospital on 18 July 2025 from an infection following an injury caused by the insertion of a urethral catheter after unsuccessful catheterisation attempts at his care home. The substantive concern was that after two unsuccessful attempts to insert a replacement catheter, arrangements should be made to take the patient to hospital without delay.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Meadows; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange prompt hospital transfer after two unsuccessful replacement catheter insertion attempts
Wider context from the report “Where there are two attempts at inserting a replacement catheter, either the same catheter, or a second catheter and both these are unsuccessful the patient will need to be taken to hospital and arrangements for this should be made as without delay .
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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 Distribute a quick-reference escalation flowchart to team leads.
Verbatim wording from the response “Distribution of a Quick Reference Flowchart for team leads (See enclosed) 23.10.25” Source location Response from High Meadows Care Home
Open published response
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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 Limit replacement-catheter insertion to two attempts, stop sooner for resistance, pain, or bleeding, and call 999 after two failures or earlier if sepsis is suspected.
Verbatim wording from the response “In summary in future the home will ensure that protocol is followed and there will be a maximum of 2 attempts at inserting a replacement catheter. The attempts will immediately cease in the event of resistance, pain or bleeding and 999 will be called immediately after 2 failed attempts or sooner if sepsis is suspected.” Source location Response from High Meadows Care Home
Open published response
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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 Record each 999 call reference number and assign a staffed phone to respond promptly to emergency-service return calls.
Verbatim wording from the response “Further, in all future emergencies, once the home contacts 999, a 999 call reference number will be recorded, and a designated staff member with an allocated phone will remain available to respond promptly to any return calls from emergency services.” Source location Response from High Meadows Care Home
Open published response
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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 Create and implement an escalation protocol.
Verbatim wording from the response “Creation and implementation of an Escalation protocol (See enclosed) 23.10.25” Source location Response from High Meadows Care Home
Open published response
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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 Create and implement a full clinical protocol for catheterisation emergencies and escalation.
Verbatim wording from the response “Creation and implementation of a Catheterisation Emergency & Escalation full clinical protocol (See enclosed) 23.10.25” Source location Response from High Meadows Care Home
Open published response
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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 face-to-face refresher training in catheterisation for all nurses and team leads.
Verbatim wording from the response “We provided a face to face refresher training session for all nurses and team leads in catheterization 12.11.25” Source location Response from High Meadows Care Home
Open published response
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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 Distribute a quick-reference catheterisation emergency poster to all nursing stations.
Verbatim wording from the response “Distribution of a Quick Reference Poster to all nursing stations for immediate guidance in urgent situations (See enclosed) 23.10.25” Source location Response from High Meadows Care Home
Open published response
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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 Review clinical documentation and escalation procedures to improve clarity and accountability.
Verbatim wording from the response “A review of clinical documentation and escalation procedures to ensure clarity and accountability. 23.10.25” Source location Response from High Meadows Care Home
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations