“the Trust made no progress on the introduction of an SOP recommended in the internal…”

The coroner’s concerns

(1) the Trust made no progress on the introduction of an SOP recommended in the internal review for almost 4 years. A draft SOP had been proposed in the weeks leading up to the inquest. (2) The expert evidence at the inquest was that the Trust's proposed action plan using CT scanning at an unspecified time before a suprapubic catheter insertion was sub optimal and inferior to ultrasound as bowel may move between the date of the CT scan and the catheter insertion; (3) in the four years since Antony Waring's death, the Trust has not provided a single ultrasound teaching session provided by the Trust to any consultant who is not capable of using ultrasound. (4) the allocation of high-risk patients to Core Lists where a specific ancillary prophylactic measure such as ultrasound is left to either chance or to an administrator; (5) The expert evidence at the inquest was that the research provided on the risk of complications after insertion of a suprapubic catheter into patients with lower abdominal surgery is inappropriate the patient such as Antony Waring and provides false reassurance as to the level of risk posed to these patients. 5.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0399

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0