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Investigation and inquest
On the 22 July 2025 I commenced an investigation into the death of, Brian Lloyd, aged 78. The investigation concluded at the end of the inquest on 21 October 2025. The conclusion of the inquest was Consequences of infection following injury during catheter insertion at a care home. The medical cause of death was 1a Septicemia, 1b Urinary Tract Infection, 1c Insertion of urethral catheter.
Circumstances of the death
On the 18th July 2025 Mr Brian James Lloyd died in hospital from an infection following injury caused by the insertion of a urethral catheter.
Mr Lloyd awoke as usual on the 12th July 2025 at his care home and all was well until his catheter became blocked. This was between 9.30 and 10.42.
A nurse attempted to flush the catheter which was not successful and the catheter was removed. There followed 2 attempts to insert a new catheter . Each of these attempts was not successful and as Mr Lloyd was distressed he was given paracetamol to ease his discomfort.
A third attempt was made at 15.40 which was also unsuccessful.
A call was then made to the London Ambulance Service at 16;26 and this was transferred to the London Central Urgent Care Center for a clinician to call the care home.
There were 3 attempts to call the care home with a connection being successful on the 4th attempt and an ambulance was arranged to take Mr Lloyd to hospital at 17;27.
When at hospital the doctors found some difficulty in inserting a catheter until using a more specialised piece of equipment usually only available at a hospital.
Despite treatment Mr Lloyd was not able to recover from the infection that arose from the insertion of the catheter and it is likely that the blood seen on the 3rd attempt at inserting the catheter at the care home was the point at which the infection was able to spread.
Coroner’s concerns
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.
Information checked against the published report and official responses