How a Nursing Expert Witness Report Uncovered Catheter Care Failures
- Apex Experts
- May 30
- 2 min read
When Standard Catheter Protocols Fail: A Medico-Legal Case Review
In this case review, we examine a real-world scenario where a nursing expert witness report identified significant lapses in catheter care within a rehabilitation unit. The patient, an elderly man recovering from surgery, developed a life-threatening infection. The findings shed light on how seemingly minor documentation and escalation failures can culminate in severe outcomes—and legal exposure.

Background of the Case
The report, compiled by an Apex nurse expert with over 25 years of clinical experience, assessed whether the standard of nursing care—specifically catheter care—met the expected level. The patient, initially recovering from a fractured neck of femur and COPD, was re-catheterised multiple times due to urinary retention. Over time, signs of sepsis emerged, including:
Strong, offensive-smelling urine
Abdominal and genital pain
Late escalation to urology
Delayed investigation of symptoms
What the Nursing Expert Witness Report Found

The nursing expert witness report identified several key failings:
Incomplete catheter care plans
No documented rationale for failed catheterisation attempts
Delayed recognition of sepsis symptoms
Lack of documentation on family-reported concerns
Disrespectful language in nursing notes (e.g., dismissive of patient's distress)
Despite initial good practice during hospital admission, the report concluded that the care in the rehabilitation unit breached acceptable nursing standards.
“In my opinion, the general documentation and catheter care at the rehab centre was generally poor and falls below a reasonable standard.”— Apex Nurse Expert Report
Legal and Clinical Implications
The report applied the Bolam and Bolitho tests, concluding that the care would not be supported by a responsible body of nurses. However, causation was deferred to a medical expert, highlighting the collaborative nature of multidisciplinary evidence in clinical negligence cases.
This case exemplifies how nursing documentation, if insufficient, can directly lead to allegations of negligence.
Why a Nursing Expert Witness Report Matters in 2025
With the rise of digital records and litigation involving catheter-associated infections, solicitors, insurers, and Trusts must:
Ensure compliance with RCN catheter care guidance
Maintain clear escalation pathways
Train nurses in medico-legal documentation best practices
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