Derek BRIERLEY · Prevention of Future Deaths report

On 17/08/2012 I commenced an investigation into the death of Derek BRIERLEY, then aged 86 Years. The investigation was concluded at the end of the inquest on 17/08/2013. The conclusion of the inquest was “Recognised but rare complication of necessary surgical intervention.”, the medical cause of death being 1a Bronchopneumonia 1b post peritonitis after insertion of suprapubic catheter for benign prostatic hyperplasia 1c blocked urethral catheter for benign prostatic hyperplasia

Mr Brierly’s catheter was not working on the morning of the 21st July 2012. A district nurse was unable to recatheterise him at home and so he was conveyed by ambulance to the Royal Oldham Hospital where three further attempts by a nurse, junior doctor and consultant were also unsuccessful by which time Mr Brierly had a palpably distended bladder. The Consultant’s attempt at a suprapubic insertion via the abdomen was abandoned following which Mr Brierly became acutely unwell with features of peritonitis

1) Although the consultant performing the suprapubic procedure had done so successfully on nine previous occasions the last such occasion was twelve months earlier. The family overheard instructions for the procedure being read out to the consultant whilst it was being carried out. More likely than not the site of the insertion was too high.

2) There are no Trust Guidelines as to the standard of competence or training of those carrying out the procedure
3)Difficulties were encountered in locating a suprapubic catheter prior to the procedure