Coroner's Finding: Krushka, Robert

66y · Male·sepsis following bacteraemia caused by transurethral catheter insertion

A 66-year-old man with severe dementia and multiple comorbidities died from sepsis following bacteraemia after a routine indwelling urinary catheter change at a nursing home. The catheter insertion was traumatic, resulting in haematuria, anuria, fever and hypotension. Despite appropriate hospital treatment including antibiotics for polymicrobial bacteraemia, he deteriorated and died. The coroner found no bladder perforation. Key clinical lesson: routine catheter replacement at fixed intervals is not evidence-based practice and may increase infection risk without clear benefit. Current guidelines recommend replacement only for mechanical problems. The coroner recommends practitioners review current evidence on catheter management protocols.