PFD report

George Richardson · Prevention of Future Deaths report

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Issued 15 May 2015•Sunderland

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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

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 raised3

  1. Lack of a consolidated catheterisation record
    Part of recurring concern: Unsafe catheterisation practice
  2. Failure to recognise previous catheterisation challenges and promote Urologist involvement
    Part of recurring concern: Unsafe catheterisation practice
  3. Lack of national standards for safe and effective catheterisation skills
    Part of recurring concern: Unsafe catheterisation practice
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Existing national catheterisation guidance is considered sufficient, so additional national guidance is not currently required.

    Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Lack of a consolidated catheterisation record

Wider context from the report

“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record. Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist. The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set. ”

Is this part of a recurring concern?

Yes — Unsafe catheterisation practice.

Open source report

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 recognise previous catheterisation challenges and promote Urologist involvement

Wider context from the report

“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record. Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist. The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set. ”

Is this part of a recurring concern?

Yes — Unsafe catheterisation practice.

Open source report

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

Lack of national standards for safe and effective catheterisation skills

Wider context from the report

“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record. Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist. The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set. ”

Is this part of a recurring concern?

Yes — Unsafe catheterisation practice.

Open source report

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing national catheterisation guidance is considered sufficient, so additional national guidance is not currently required.

Verbatim wording from the response

“Appropriate national guidance already exists. Ensuring staff know of it, and how and when to seek help where catheterisation proves problematic, is for hospital Trusts to action locally. For the future, should BAUS determine a need for further national advice, NHS England would support its dissemination.”

Source location

2015-0189-Response-by-Department-of-Health
Page 2 · response
Published 15 May 2015

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Hospital Trusts are responsible for locally ensuring staff know the guidance and when to seek specialist help during difficult catheterisation.

Verbatim wording from the response

“Appropriate national guidance already exists. Ensuring staff know of it, and how and when to seek help where catheterisation proves problematic, is for hospital Trusts to action locally. For the future, should BAUS determine a need for further national advice, NHS England would support its dissemination.”

Source location

2015-0189-Response-by-Department-of-Health
Page 2 · response
Published 15 May 2015

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

BAUS considers decisions about seeking senior help after repeated failed catheterisation attempts best addressed through local rather than national guidance.

Verbatim wording from the response

“The British Association of Urological Surgeons (BAUS) has advised that the issue of when and how to seek more senior help following repeated failed attempts at catheterisation is best managed by local, rather than national, guidance.”

Source location

2015-0189-Response-by-Department-of-Health
Page 2 · response
Published 15 May 2015

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