Mr W and his wife, Mrs W, complained about care provided to Mr W by the Health Board in February 2025. Specifically, the investigation considered whether Mr W’s trial without catheter (“TWOC” – when the catheter is removed to see if a patient is able to empty the bladder completely), and subsequent re-catheterisation, was managed appropriately. It also considered whether complications which arose during Mr W’s subsequent surgery were appropriately managed and communicated to him and whether Mr W’s post-operative infection was recognised and treated promptly.
The investigation found failings by the Health Board to appropriately monitor Mr W during the TWOC as an excessive volume of urine had been allowed to accumulate that likely caused damage to Mr W’s bladder and led to the requirement for later surgery to repair it. This aspect of Mr W’s complaint was upheld. The investigation found that, whilst complications which arose during Mr W’s surgery on 19 February were appropriately managed, discussions and explanations provided to Mr W following the operation were not appropriately documented. On this basis, the investigation found that Mr W had not been given a full and timely opportunity to ask relevant questions and gain a full understanding of what had happened and why. To that extent only, this part of Mr W’s complaint was upheld. Finally, the investigation found that, when there were indications of possible post-operative infection, the Health Board took appropriate and prompt action to treat Mr W and this complaint was not upheld.
The Health Board agreed to apologise to Mr W and Mrs W for the failings identified in this report. It also agreed to remind all staff who provide care and treatment during TWOC procedures of the expectations and importance of providing standards of care in line with protocol. In addition, the Health Board agreed to share this report with the relevant services and remind staff of the importance of clearly documenting clinical care and discussions with patients and their family in line with relevant guidance and of the need for appropriately robust and proportionate complaint investigations. The Health Board said it would complete these actions within one month of the final report.