Hackney 87-year-old died after medics failed to change catheter for a year
- Credit: Archant
An inquest has found Homerton Hospital and a GP practice failed to change an 87-year-old's indwelling catheter for almost a year, leading to his death.
Macaulay Wilson died in September last year, leading to an investigation being launched by senior coroner Mary Hassell, from St Pancras Coroner’s Court, on October 8.
In a prevention of future deaths report, published at the conclusion of the inquest on on May 7, Ms Hassell wrote: "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 coroner warned of a "risk of future deaths" unless "action is taken", after reporting that Homerton Hospital's urology department failed to risk-asses Mr Wilson's catheter change requirement.
Hassell said Homerton did not "recognise that [the procedure] was too complex medically for district nurses in the community", adding that it should have been dealt with by the department.
The coroner said Homerton Hospital wrote to Lower Clapton Group Practice in February 2019, requesting that district nurses change Mr Wilson's catheter in 12 weeks.
Ms Hassell wrote: "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."
The report says Homerton Hospital repeatedly "failed" to reschedule an appointment cancelled due to the Covid pandemic.
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The coroner added: "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.”
A spokesperson for Homerton Hospital offered "sincere condolences" to Mr Wilson's family and acknowledged a "number of issues", including "a breakdown in communication" between the hospital and Mr Wilson's GP practice.
They added: "The trust has thoroughly reviewed Mr Wilson’s case and has implemented an action plan in which the hospital’s urology department ensures that district nursing teams are kept informed of patient treatment plans along with each patient’s GP.
"We have also tightened the procedures for assessing catheter changing requirements by conducting regular audits of all patients in the community with indwelling catheters."
Lower Clapton Group Practice was notified of a duty to respond to the coroner by July 5, detailing actions to prevent future deaths.
The practice has been contacted for comment.