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National Patient Safety Agency

Hospitals alerted to risks of inserting suprapubic catheters incorrectly

Thursday 30 July 2009


NHS hospitals across England and Wales are being alerted to the risks of using suprapubic catheters after a number of patients suffered severe harm or fatal injuries as a result of error.


The guidance comes from the National Patient Safety Agency (NPSA) after three patients died and seven were severely harmed after the devices were incorrectly inserted.


Suprapubic catheters are used to drain patients’ bladders when they are blocked or when a urinary catheter cannot be inserted.  They may also be used in patients with spinal injuries or neurological conditions such as multiple sclerosis and for some undergoing surgery. 


Dr Kevin Cleary, Medical Director at the NPSA, said: “We hope our advice will be seen as supporting clinicians and NHS trusts to minimise harm to patients. 


“Although the procedure is relatively common and carried out in most hospitals, the risks are not always understood.  The data we received between September 2005 and June 2009 concluded that on occasions this technique was conducted by staff without proper support, training or equipment.  When errors do occur, it can lead to patients suffering internal bleeding or experiencing other complications.  As we have seen through our reports, in the most extreme cases, patients have died.”


One of the recommendations outlined in the alert (known as a Rapid Response Report) is for clinicians to use ultrasound machines when inserting these suprapubic catheters.


“This is to ensure urologists and other relevant staff can accurately navigate the drainage tube into the bladder without piercing the bowel.  It is vital all relevant staff are aware of how to use these machines when carrying out this procedure,” Dr Cleary added.


The British Association of Urological Surgeons (BAUS) is currently developing national guidelines on suprapubic catheterisation, which will provide more detailed information on best practice for clinical staff.


Derek Fawcett, President of the British Association of Urological Surgeons, welcomed the latest advice from the NPSA:


“The British Association of Urological Surgeons fully supports the NPSA in alerting the public and the profession to the potential dangers of suprapubic catheterisation.

“Suprapubic catheterisation is an essential part of urological practice and this report serves as a timely reminder of the potential dangers. When used by trained and experienced practitioners it remains a safe and entirely proper way of helping some patients after bladder operations and in relieving distressing urinary difficulties.”


View the Rapid Response Report.




Notes to Editors:


For all media enquiries, contact the NPSA Press Office:


Simon Morgan, Senior Media Manager

020 7927 9580 / simon.morgan@npsa.nhs.uk


Paul Cooney, Press Officer

020 7927 9351 / paul.cooney@npsa.nhs.uk


Out of hours

0788 411 5956



What are suprapubic catheters?

A suprapubic catheter is a hollow, flexible tube which drains urine from a patient’s bladder into a bag, which is strapped to the patient’s leg or next to their bed. The tube is inserted through a small cut in the abdominal wall just above the pubic bone. This is done by a doctor in hospital.


For more information visit NHS Choices.



What has been reported to the NPSA?

Between 01/09/2005 and 30/06/2009, 259 incidents were reported to the NPSA’s Reporting and Learning System relating to the insertion and management of suprapubic catheters.


Of these, nine resulted in bowel perforation – three deaths and seven cases of severe harm.


Degree of harm

No. of incidents

Bowel perforation




Severe harm



Moderate harm



Low harm



No harm
















For more information view the Supporting Information to the Rapid Response Report.




The National Patient Safety Agency is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations.