PFD report

Macaulay WILSON · Prevention of Future Deaths report

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Issued 7 May 2021•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to use specific language distinguishing catheter change from catheter care in requests
    Part of recurring concern: Unreliable management of urinary cathetersPart of recurring concern: Unreliable referrals to district nursing services
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Highlight instructions for other clinical teams and send the original correspondence with onward referrals.

    Stated by Lower Clapton Group PracticeStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
  2. Action

    Communicate the revised processes to the team and incorporate them into the induction programme.

    Stated by Lower Clapton Group PracticeStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to use specific language distinguishing catheter change from catheter care in requests

Wider context from the report

“The Homerton University Hospital urology clinical nurse specialist wrote to your practice on 18 February 2019, and included within the letter a request that you arrange for district nurses to change Mr Wilson’s indwelling catheter in 12 weeks. A doctor from your practice did consider the letter, did action it and did write to the district nurses, but did not include a specific request for catheter change (as opposed to catheter care, which does not include change of the catheter). It seems that your doctors’ use of language in this situation would benefit from further consideration. ”

Is this part of a recurring concern?

Yes — Unreliable management of urinary catheters; Unreliable referrals to district nursing services.

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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

Highlight instructions for other clinical teams and send the original correspondence with onward referrals.

Verbatim wording from the response

“Lower Clapton Group Practice has introduced a system to ensure that when the practice receives correspondence containing instructions directed towards other members of the wider clinical team involved in a patient’s care, such as district nursing, the relevant instructions will be clearly highlighted and a copy of the original letter will accompany any onward referral to ensure there is no loss of information or message clarity. We are undertaking an audit of all patients who have catheter products on their prescriptions. We will ensure that we clearly record in their notes how frequently their catheter should be changed and which service is responsible for doing this. We have written an electronic template within our clinical system to aid us in capturing the above data.”

Source location

2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
Page 1 · response
Published 18 May 2021

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

Communicate the revised processes to the team and incorporate them into the induction programme.

Verbatim wording from the response

“We have communicated the above to all members of the team including the person responsible for coding incoming patient related correspondence and these processes have been incorporated into our induction program. We have informed our local medicines management team about this case to ensure they can disseminate this risk within their monthly newsletter so that other practices can ensure a similar event does not occur. We have reported the incident via the National Reporting and Learning System and have informed the CCG. We are amending the City and Hackney wide EMIS template which is used when visiting housebound and vulnerable patients to include parameters such as catheters and catheter change as well as other issues which may increase patient risk such as pressure sores and falls.”

Source location

2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
Page 1 · response
Published 18 May 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Use an electronic alert to prompt checks of catheter change dates and responsible services for patients receiving catheter products.

    Stated by Lower Clapton Group PracticeStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
  2. 2

    Use an electronic template to capture catheter care, change frequency and responsible-team information.

    Stated by Lower Clapton Group PracticeStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
  3. 3

    Amend the city-wide EMIS template to capture catheter changes and other patient-risk factors during visits.

    Stated by Lower Clapton Group PracticeStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
  4. 4

    Record catheter change frequency and the responsible service for patients with new indwelling catheters.

    Stated by Lower Clapton Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
  5. 5

    Audit all patients prescribed catheter products.

    Stated by Lower Clapton Group PracticeStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.

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

Use an electronic alert to prompt checks of catheter change dates and responsible services for patients receiving catheter products.

Verbatim wording from the response

“This will be completed for all patients with a new indwelling catheter to ensure we have accurate information in connection with catheter care, catheter change frequency and the identity of the responsible team. We have written an electronic alert which activates when a patient is identified as being in receipt of catheter products (from their prescription page). This will prompt users to check for when a patient’s catheter was last changed and identify which part of the service holds responsibility for this.”

Source location

2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
Page 1 · response
Published 18 May 2021

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

Use an electronic template to capture catheter care, change frequency and responsible-team information.

Verbatim wording from the response

“Lower Clapton Group Practice has introduced a system to ensure that when the practice receives correspondence containing instructions directed towards other members of the wider clinical team involved in a patient’s care, such as district nursing, the relevant instructions will be clearly highlighted and a copy of the original letter will accompany any onward referral to ensure there is no loss of information or message clarity. We are undertaking an audit of all patients who have catheter products on their prescriptions. We will ensure that we clearly record in their notes how frequently their catheter should be changed and which service is responsible for doing this. We have written an electronic template within our clinical system to aid us in capturing the above data.”

Source location

2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
Page 1 · response
Published 18 May 2021

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

Amend the city-wide EMIS template to capture catheter changes and other patient-risk factors during visits.

Verbatim wording from the response

“We have communicated the above to all members of the team including the person responsible for coding incoming patient related correspondence and these processes have been incorporated into our induction program. We have informed our local medicines management team about this case to ensure they can disseminate this risk within their monthly newsletter so that other practices can ensure a similar event does not occur. We have reported the incident via the National Reporting and Learning System and have informed the CCG. We are amending the City and Hackney wide EMIS template which is used when visiting housebound and vulnerable patients to include parameters such as catheters and catheter change as well as other issues which may increase patient risk such as pressure sores and falls.”

Source location

2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
Page 1 · response
Published 18 May 2021

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

Record catheter change frequency and the responsible service for patients with new indwelling catheters.

Verbatim wording from the response

“Lower Clapton Group Practice has introduced a system to ensure that when the practice receives correspondence containing instructions directed towards other members of the wider clinical team involved in a patient’s care, such as district nursing, the relevant instructions will be clearly highlighted and a copy of the original letter will accompany any onward referral to ensure there is no loss of information or message clarity. We are undertaking an audit of all patients who have catheter products on their prescriptions. We will ensure that we clearly record in their notes how frequently their catheter should be changed and which service is responsible for doing this. We have written an electronic template within our clinical system to aid us in capturing the above data.”

Source location

2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
Page 1 · response
Published 18 May 2021

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

Audit all patients prescribed catheter products.

Verbatim wording from the response

“Lower Clapton Group Practice has introduced a system to ensure that when the practice receives correspondence containing instructions directed towards other members of the wider clinical team involved in a patient’s care, such as district nursing, the relevant instructions will be clearly highlighted and a copy of the original letter will accompany any onward referral to ensure there is no loss of information or message clarity. We are undertaking an audit of all patients who have catheter products on their prescriptions. We will ensure that we clearly record in their notes how frequently their catheter should be changed and which service is responsible for doing this. We have written an electronic template within our clinical system to aid us in capturing the above data.”

Source location

2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
Page 1 · response
Published 18 May 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026