Coroner's Finding: DAVIES Harold Leslie

87y · Male·multi organ failure due to septic shock complicating urinary tract infection and traumatic bladder catheterisation

An 87-year-old man with atrial fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful attempt by an RDNS nurse followed by a procedure by the patient's GP. Subsequently, massive haematuria developed. An ambulance was initially called but cancelled on the GP's instructions before being re-called; the delay may not have altered outcomes. Key issues included: the appropriateness of catheterisation in a nursing home setting given anticoagulation, the patient's preference for RDNS over his GP based on prior discomfort, uncertainty about which procedure caused the trauma, and failure to provide antibiotic prophylaxis despite chronic catheterisation and infection history. The case illustrates risks of performing invasive procedures in uncontrolled environments in vulnerable patients.