Recurance · prevention of future deaths reports
Pre-inquest brief
Repeated catheterisation without oversight or documentation
The earlier warning
Stephen Widman · 29 Apr 2014 · Ian Arrow, Plymouth, Torbay & South Devon
“The deceased was catheterised too frequently without the management of a urologist.”
What was promised
No published response from Department of Health and Social Care was found for the earlier reports.
What recurred
- 15 May 2015 · George Richardson · Derek Winter · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Stephen Widman · 29 Apr 2014
“The deceased was catheterised too frequently without the management of a urologist.”
Later · George Richardson · 15 May 2015
“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record.”
What happened next
No web check of the stated actions has been published for this chain.