How Could You Have Forgotten My Catheter Doctor, I Haven't

Urinary catheters are amongst the commonest interventions in the NHS, and one of the easiest to lose track of. Catheter-associated urinary tract infection (CAUTI) is the single most common healthcare-associated infection in acute hospitals. Infection is only the headline complication: many carrying that risk longest also live with chronic disease and frailty, exactly the population World Patient Safety Day 2026's theme of 'safe care for noncommunicable diseases' targets. For them, a forgotten catheter becomes another long-term condition nobody owns- a feature of system design rather than an individual lapse.

Without planned review, a catheter causes harm well beyond infection. Biofilm crystalizes until catheter block, urine bypasses, and can calcify into a bladder stone. Blockage and bypassing generate a disproportionate share of unplanned contact, district nursing callouts, out-of-hours calls, emergency attendances. Pressure injury and urethral erosion affect roughly one in ten of those catheterised for four weeks or longer, progressing silently unless sought out.

Pain, involuntary bladder spasms and leakage affect many long-term users, two-thirds reporting it at least once a year. Patients also describe restricted activity, disrupted sleep, reduced social participation and loss of sexual activity.

A man in his sixties has waited over two years for prostate surgery, catheterised throughout. His review plan after a failed trial of voiding was noted simply as 'admit for surgery'. Urology waiting lists remain long, and patients like him often have prolonged waits for definitive treatment. His catheter, initially a temporising measure, has been in place so long that a bladder stone has now formed, adding symptoms, unplanned care and a longer, more complex operation.

SEIPS (Systems Engineering Initiative for Patient Safety) is the work-system model that underpins NHS England's Patient Safety Incident Response Framework. It asks not who forgot the catheter, but what in the surrounding work system, the people, tasks, tools and technology, organisation, and physical and social environment, made forgetting it likely to happen. The Task element is covered by protocols such as HOUDINI which already lists the accepted indications for inserting or continuing a catheter, and hospitals that use it consistently have lower CAUTI rates. The recurring failure sits elsewhere. There is a Tools and Technology gap where most catheter documentation is an entry in contemporaneous notes or a discharge letter, not systems that automatically prompt review. There is an Organisation gap as a catheter is usually inserted to manage the immediate problem. Whether it is still needed and any plans for review are often with another person or team. An Environment gap occurs as the same patient moves between hospital, GP, community nursing and social care over months or years, each seeing only a fragment of the story. Reviews of inappropriate catheterisation consistently find clinicians are unclear how long a catheter has even been in place.

A 93-year-old man was catheterised for fluid monitoring whilst confused after a fall. His discharge summary describes the catheter as 'long-term', closing the question of ever trying without it; a trial without catheter is never arranged. Eighteen months later he is referred to urology because his ventral urethra has eroded through to the base of his scrotum. Nobody made one wrong decision; a word on a discharge letter, unquestioned for eighteen months, stood in for a review that never happened.

Scotland's national Urinary Catheter Passport, developed through the Scottish Urinary Tract Infection Network, is a rare working answer to exactly this failure: a single patient-held record documenting why the catheter was inserted, every change, and every trial without catheter attempted. Its value is best understood through Safety-II, the resilience-engineering view that safety comes less from preventing any single point of failure than from building everyday capacity, across many people and contacts, to notice and correct drift before it becomes harm. A passport does not rely on one clinician remembering; it puts the same question, why is this catheter still here, in front of every GP, district nurse, ward team and clinic that sees the patient, so that any one of many contacts can catch what the others missed. England’s GIRFT (Getting it right first time) national catheter care guidance, published May 2026, now makes the same recommendation, that every catheter patient should have a passport, checked at every discharge, community review and primary care consultation. Yet an audit of one general practice found five patients with an indwelling catheter, four of whom had attended the emergency department with catheter problems in the past year, none had a passport. Both nations now recommend a gap remains unless it is issued and used effectively.

For any catheter we should know why it was inserted, who is responsible for review, and when a trial without catheter was last attempted. Where we cannot answer all three, the catheter has already been forgotten by the system - everyone except the patient, who is reminded of its presence constantly.