"Failed action on urinary retention"

About: Lincoln County Hospital / General surgery

(as a service user),

I was recently admitted to SEAU. I had been seen in surgical ambulatory the previous day after a GP referral for a perineal abscess. I returned to surgical ambulatory in the morning.

The theatre porter came to get me before I had been formally admitted and so it was all very rushed and none of the staff members on SEAU introduced themselves to me. At this point it was two members of staff.

In theatre I had a spinal anaesthetic as advised by the anaesthetist due to the coronavirus pandemic.

As soon as I returned to the ward, I began to feel a discomfort in my stomach. Within minutes, this discomfort developed into sharp pains in my lower abdomen. I mentioned it to a member of staff, who appeared to ignore me (once again this staff member did not introduce themselves to me, I just overheard names).

The pain was constantly increasing, and I had noticed that if I pressed on my lower abdomen, the pain intensified, and my abdomen felt hard. I began to wonder if it was a full bladder causing me the pain. I then told another member of staff about the pain and that it increased on pressing and that I thought it may be my bladder, they said to me that I had been to the toilet before I left for theatre and told me not to press my stomach if it hurt and left.  

The pain and feeling of intense pressure were agonising. I was left alone, no one appeared to be concerned about the amount of pain I was in. I called for the someone again and I mentioned to them that I thought I needed to empty my bladder but that I still could not feel any sensation in my perineal area. they were very dismissive of me again and said if I wanted to try to urinate then they would have to get me a bedpan but seemed somewhat annoyed by this. I said that as my legs felt as though they were starting to get back to normal, maybe I could try a commode. They agreed and brought me the commode. They put my curtains round and left me to get on the commode, however, did not put my call bell within reach. I sat there for a while but was unable to pass anything and the pain each time I attempted to move to get back onto the bed, was excruciating, I did however make it back onto the bed.

I managed to reach my call bell once back on the bed. The same member of staff came in and opened the curtains but left the commode. I explained I could not pass anything and the amount of pain I was in. Two staff members stood at the end of the bed and said they would give it a bit longer and if it didn’t improve, they would bladder scan me, I believe they then went off for their break.  

I then proceeded to call my Husband, who is a medical professional himself, to help me as nobody seemed to want to. I was beginning to get more and more distressed. During the call, a member of staff came to record my observations. At this point I was so distressed, they agreed to bladder scan me, this was approximately just over one hour from me first mentioning my pain as I got back to the ward. The bladder scan showed 855ml in my bladder. They said to me it's no wonder that I was uncomfortable, and went to two senior staff members who were near to my bed I believe to tell them. I heard them say they were going for their lunch and then everyone disappeared, without any communication to me.

I called my Husband again, this time crying out in pain, no one seemed to want to help me and I was scared. I called the bell at least twice more, both times being told that there was no one available at the moment to catheterise me or also that they were too busy.

In desperation, I asked for my curtains to be closed again to try another time on the commode, by this time I could not control myself when I was shouting out in pain, still no one came to help me. I called my husband again and pleaded for him to help me. He called the ward a total of 29 times, before finally getting through to somebody after 20 minutes.  The person he spoke to stated that they were very busy. My husband then stated that he was a medical professional and that urinary retention was a urological emergency. It just so happened that the staff at this point came off their break and he was told they were going to catheterise me. I spoke to my husband again after his call with the ward but seemed to wait a good while again before anyone came to me.

Two staff members came in with a trolley and began setting up. I remember seeing one of them drop something on the floor and pick it up, unfortunately due to the amount of pain I was in I did not take notice if they had their gloves on at this point. However, as a medical worker myself and someone who adheres to strict aseptic technique, I can remember thinking why didn’t they leave it on the floor until they had finished the procedure. They then proceeded to use 3 different catheters and insert the same catheter numerous times before being successful. Unfortunately, they did not have a leg bag ready and so urine soaked the sheets and part filled a commode pan. Once the leg bag was fitted it very quickly drained 1L of urine into the bag. The catheter insertion happened over 2 hours after I first began complaining of pain.

I have since developed a suspected catheter related UTI and have been prescribed Co-amoxiclav in the community.

After the urine had drained, sensation in the perineal area quickly returned and due to this, the catheter soon became uncomfortable. I asked when it could be removed, and was told it was a doctor’s decision. I waited another half and hour or so and asked again when I saw a member of staff go past how long they thought it might be. They seemed annoyed with me and stated it would have to be a senior review to have it removed and that it could be a long time as they were probably still in theatre, I felt that they were intentionally dismissive of me. Thankfully, the surgical ACP who I had seen the day before overheard this and after going away, asked a healthcare support worker to come back to me and remove the catheter. As soon as she did, I urinated in the toilet.

From this point I had no more communication with the previous two members of staff. This was until one of them thrust my EDD at me without communication. I asked if I’m OK to go now and would it be possible to take some dressings home. They abruptly said yes and walked away, asking a health care support worker to get me the dressings.

In conclusion, I went into a urological emergency of urinary retention. Initially I was disregarded and even after this was the established diagnosis, it was not acted upon until various staff members had finished their breaks and lunches. Clearly this was not seen as an emergency and therefore there is a massive oversight in their training or there is a lack of empathy and probity, in seeing a patient with a reversible cause in agony.

This has caused me a great deal of anxiety and stress and I feel extremely apprehensive if I were to need to go into hospital again.


Response from Bridy Clark, Head of Nursing for Surgery/TACC, United Lincolnshire Hospitals NHS Trust last month
Bridy Clark
Head of Nursing for Surgery/TACC,
United Lincolnshire Hospitals NHS Trust
Submitted on 09/06/2020 at 16:08
Published on Care Opinion at 16:09

I am very disappointed to read of your admission to the Surgical Emergency Assessment Unit at Lincoln Hospital. I would like an opportunity to discuss these issues with you; could you please contact me directly at either: Bridy.clark@ulh.nhs.uk or by phone on 01522 597829

Thank you

Bridy Clark

Divisional Nurse Surgery

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Response from Natalie Beaumont, Junior Sister, Lincoln SEAU, United Lincolnshire Hospitals NHS Trust last month
Natalie Beaumont
Junior Sister, Lincoln SEAU,
United Lincolnshire Hospitals NHS Trust
Submitted on 10/06/2020 at 09:15
Published on Care Opinion at 11:33

I am pleased we have managed to speak since you raised your concerns. We are so sorry to hear that your experience caused you additional distress and please be assured that your concerns will be addressed. Our intention is to provide a high standard of care competently and compassionately to all our patients and your description falls well below the standards we are expected to deliver. We hope that you continue to make a good recovery since your discharge and will be in contact soon.

Kindest Regards Natalie Beaumont. Deputy Sister

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