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Hackney man died of sepsis after catheter was left unchanged for 'almost a year'

Document Cited in Related
Vincent
Published date18 June 2021
Date18 June 2021
Macaulay Wilson, 87, of Homerton, died on September 26, 2020, after Homerton Hospital and a local GP practice failed to change his indwelling catheter for 'almost a year'.

His catheter should have been changed at least four times in that timeframe, to help with the management of his bladder cancer, reports the Hackney Citizen.

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An investigation by Mary Hassell, a senior coroner at St Pancras Coroner’s Court, found failure to do so led to urosepsis, a type of sepsis linked to infection of the urinary tract.

The inquest on October 8 2020 found this oversight to have caused Mr Wilson's death.

Coroner Hassell wrote in the 'Prevention of Future Deaths report' from May 7 2021 that there was a "risk that future deaths will occur unless action is taken" by Homerton Hospital and Lower Clapton Group Practice.

Coroner Hassell wrote: "I made a determination at the inquest that Mr Wilson died because a failure to change his indwelling catheter for almost a year caused urosepsis.

"The catheter should have been changed every 12 weeks."

The inquest found that Homerton Hospital had failed to properly risk assess Mr Wilson's catheter change requirement as "too complex medically" to be dealt with by district nurses in the community.

It also found the hospital cancelled an appointment for Mr Wilson scheduled for April 27 2020 and twice failed to reschedule his appointment, despite a second referral from his GP on July 31 2020.

Meanwhile, the Homerton University Hospital district nurses "visited Mr Wilson every week for catheter care, but never enquired as to whether there had been any catheter change."

The inquest found a doctor at Mr Wilson's GP practice had neglected to specify that the catheter should be changed while instructing the district nurses.

This was despite a letter sent to Mr Wilson's GP by the urology clinical nurse specialist at the hospital on February 18 2019 specifically requesting that the catheter be changed by district nurses every 12 weeks.

The report found clearer wording should be used in future to prevent similar miscommunication...

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