Macaulay Wilson
7 May 2021 · Coroner Mary Hassell · Inner North London
The coroner's concerns
1. catheter change risk
“Homerton University Hospital urology department failed to risk assess his catheter change requirement and so did not recognise that this was too complex medically for district nurses in the community and should be dealt with by the department”
2. lack of catheter change monitoring
“the Homerton University Hospital district nurses visited Mr [name redacted] every week for catheter care, but never enquired as to whether there had been any catheter change”
3. communication ambiguity
“your doctors' use of language in this situation would benefit from further consideration”