A CORONER who ruled the death of a hospital patient following a catheter fitting was contributed to by neglect has been told procedures have been overhauled.

County senior coroner Dr James Adeley also questioned why East Lancashire Hospitals NHS Trust (ELHT) had apparently made no progress on a standard operating procedure to fix the problem in four years and why more surgeons had not been trained in ultrasound scanning.

He was told at an inquest in April that Antony Waring, who had multiple sclerosis and had problems with his small bowel, had been admitted to the Royal Blackburn Hospital to fit a catheter, as problems had developed with an existing device.

Mr Waring had undergone abdominal surgery as a result of his original problem and one consultant described the insertion of a supra-pubic catheter as a “difficult and risky procedure” due to the past operations.

The court heard no referral was made to a urological consultant with CT scanning experience.

Mr Waring’s operation took place on June 12, 2020, during which two loops of his small bowel were perforated as the catheter was being introduced.

Dr Adeley reported later that Mr Waring was then admitted to intensive care with peritonitis and died 12 days later.

The senior coroner conclusion was Mr Waring died “following a highly inappropriate choice of urological surgical technique for the insertion of the suprapubic catheter causing perforation to the small bowel and resulting in a major laparotomy and admission to the intensive therapy unit.

“Subsequent necessary feeding via a nasogastric tube in the oesophagus resulted in an aspiration pneumonia. Mr Waring’s death was contributed to by neglect.”

Dr Adeley also issued a prevention of death notice to ELHT on five grounds.

He firstly contended the trust had “made no progress on the introduction of an SOP (standard operating procedure) recommended in the internal review for almost four years. A draft SOP had been proposed in the weeks leading up to the inquest.”

A trust action plan for CT scanning as “inferior and “sub-optimal”, according to expert evidence.

Dr Adeley also reported in the four years since Mr Waring’s death no ultrasound teaching session had been provided for those not trained in the procedure.

He also questioned whether the allocation of high-risk patients to core surgery lists was “left to either chance or an administrator”.

The notice also alleged patients were being given “false reassurances” over the risks of such procedures when lower abdominal surgery had taken place.

In a letter to Dr Adeley, the chief executive of ELHT, Martin Hodgson, said: “The trust fully accepts the findings of HM Coroner and are truly sorry that Antony did not receive the treatment and care we would expect him to receive.”

He confirmed a standard operating procedure was now place for ‘non-routine’ catheter cases where a patient has a previous history of bowel, bladder or abdominal laparoscopic surgery.

Under the new complex cases procedure a consultant urological surgeon and consultant radiologist, with expertise in ultrasound scanning, would be present for Royal Blackburn Hospital cases.

Mr Hodgson said all consultant urologists were trained to scan patients to a standard level but cases such as Mr Waring’s were so rare and complex it was “practically not feasible” to train all consultants to this level.

He also told the coroner weekly meetings were held, led by the trust’s urology clinical director, to oversee surgery lists, which should include checks on pre-operation requirements for all patients.

Mr Hodgson said the trust had also reviewed its advice on such procedures and introduced changes as a result of the inquest findings.