Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.1581/01-02
Complaint against Southend Hospital NHS Trust
Summary of Case
Miss J underwent an emergency appendectomy at Southend Hospital. Post-operatively she was unable to pass urine and became increasingly uncomfortable and distressed. She informed the nurses of her discomfort and was told that she could be catheterised or she could wait until morning when she would automatically pass urine upon waking. At 5.00am,
17 hours after last passing urine, Miss J asked to be catheterised. The catheter remained in place for 30 hours. It was removed at 10.00am on 21 January. However, despite receiving intravenous fluid, Miss J did not pass urine until 7.00am on 22 January, a period of 21 hours. She was then discharged although there was no indication that she was able to pass appropriate amounts of urine spontaneously. Approximately one month after discharge, she was seen by a surgical senior house officer in a routine out-patient appointment. He recognised that there was a continuing urological problem and referred her to a consultant urologist. Miss J saw the consultant urologist on 8 March and she was referred for training in intermittent self-catheterisation. Miss J complained to the Trust that following her appendectomy she was left in urinary retention for a prolonged period without appropriate intervention.
Findings
The Ombudsman concluded that in accordance with the Trust’s pre-operative care plan, Miss J should have been catheterised within 12 hours post-operatively and that, once the catheter had been removed, it was the responsibility of the nursing and medical staff to ensure that the patient was passing adequate volumes of urine and was emptying her bladder properly prior to discharge. She was concerned that Miss J had not been reviewed by a consultant during her admission to hospital. The Ombudsman criticised nursing and medical staff for failing to manage Miss J’s urinary retention appropriately. She also criticised the Trust for having no written policy on post-operative care and urinary retention. The Ombudsman considered that the Trust’s standard of record-keeping was inadequate, in particular that there was no evidence of any communication between the medical and nursing staff, and the information on the fluid balance chart was scarce and incomplete.
Remedy
The Ombudsman recommended that the Trust develop guidance for staff on the risks and implications of post-operative urinary retention and the importance of timely catheter introduction. She further recommended that the Trust produce a patient advice leaflet about the possibility of post-operative complications such as urinary retention and its symptoms. In regard to record-keeping, the Ombudsman recommended that the Trust undertake a full review of its nursing documentation procedures and review and monitor its nurse training arrangements to make sure that the high standards of record-keeping expected of nurses are both promoted and achieved.
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