Graham White

BAUS Response to HSIB document 

BAUS and the BAUS Section of Endourology acknowledges the Healthcare Safety 
Investigation Branch (HSIB) investigation into the delayed removal of a JJ stent, the 
specific need to log and track ureteric stents and the benefit of improved GP and 
patient communication for patients in whom a JJ stent has been inserted. We agree 
that ensuring patients and their GP are aware of the potential symptoms from stents, 
including symptoms mimicking urinary tract infection (UTI), as well as confirmed 
symptomatic microbiologically confirmed UTI that could be caused by a stent. We 
also agree that a clear plan of when, where and how the stent should be removed 
should be explicitly communicated to both the patient and the GP. 

We confirm that we have noted the following key findings of the report: 

• There is currently no national stent register being used across the NHS. 
• Hospitals deploy a range of systems to track and log stent insertion. Some trusts 
also have systems to reconcile stent removal (that is, to log the removal of each 
patient’s stent against the record of its insertion). Paper-based stent logging/tracking 
appears to be effective in the absence of electronic systems. 
• The combination of human oversight and effective stent logging/tracking systems 
may be beneficial in preventing delayed removal of stents. Systems should not rely 
solely on human oversight. 
• Other medical specialties which use ureteric stents may not use the same stent 
logging/tracking systems as the urology team. 
• Patients being discharged with stents in situ need clear and consistent 
communication, both verbally and in writing. 
• Involving patients in their care has been shown to improve the quality and 
experience of care. 
• The written advice available for patients with ureteric stents is inconsistent across 
the country. 
• Poor communication may lead to loss of opportunity for patients to self-care and be 
aware of potential complications with their stents. 
• Clear information given to patients with tethered stents (stents that can be removed 
by the patient) ensures compliance with their planned removal schedule. 
• GPs and other clinical staff working in primary and urgent care services may not be 
aware of the side effects and complications associated with ureteric stents. 
• Hospital discharge letters and other communications do not carry standardised 
information for healthcare professionals about ureteric stents. 
• The Summary Care Record system (which makes an electronically collated version 
of patients’ healthcare records accessible to a range of clinical services) does not 
currently have a ‘flag’ or other method of identifying patients with ureteric stents.  

In response to the report, the issues raised have been discussed at length during 
BAUS Section of Endourology committee meetings, and further input has been 
sought from the Urology GIRFT Joint National Clinical Leads (

), 

 in his role as NHSE National 

 
 
 
 Clinical Lead for Innovation, and 
for Urology. 

, NCIP National Clinical Lead 

The theme of these meetings has been to agree that the morbidity of an 
inappropriately prolonged JJ stent dwell time is considerable and that encrusted 
stents represent a complex endourological challenge for their removal and 
subsequent patient management, including the possibility of loss of renal function.  

However, whist we fully appreciate the consequences of the individual cases where 
this occurs and share the HSIB goal to improve patient safety by mitigating the risk 
of overdue stent removal or change, there is no clear picture as to the scale of the 
problem of delayed stent removal.  

We do not have access to data that gives either the numerator of the number of 
encrusted stents in the UK per year, nor the denominator for the total number of 
stents that are inserted or changed in the UK per year. We feel that this data is vital 
to our understanding the scale of the problem of delayed stent removals and the 
impact of this on patients, as well as the associated medico-legal costs to the NHS.   

Furthermore, as has been clearly elucidated in the HSIB report, stent tracking is a 
complex process requiring considerable IT and human resources.  It relies on 
accurate record keeping for both the initial stent insertion as well as subsequent 
removal or exchange of that stent.  The solutions will therefore require investment 
both in IT and personnel, as well as time to achieve the goal of reduced stent-dwell 
morbidity.  

On this background, we have answered the HSIB report’s Safety recommendations 
and observations as follows.  

Safety recommendation R/2020/091:  

It is recommended that the British Association of Urological Surgeons, in 
collaboration with other relevant specialties (such as the Royal College of 
Radiologists and British Transplant Society), develops national standards which 
support electronic and paper-based systems for stent logging/tracking. These 
standards should include guidance on monitoring and human oversight.  

We agree with the HSIB recommendation that the insertion of a JJ stent should be a 
clear part of the operation note and discharge summary.  In addition, we agree that 
some form of localised stent tracking is mandatory, but in the absence of a 
centralised NHS digital solution for tracking temporary implantable devices (such as 
stents and catheters), it is difficult for BAUS and partner organisations to develop 
consistent national standards.  We recognise that Trusts across the country employ 
a range of mechanisms to track ureteric stents currently, and that these vary in terms 
of the human oversight required as well as in their integration with existing electronic 
patient care records.  As a minimum standard, we suggest that: 

1.  Reasons for, and details of the ureteric stent insertion are clearly recorded 
in the operative record, or on a specific proforma which is to be attached to 
the patient’s notes (an example can be found in Appendix 1).  

 2.  All urology departments have a system in place to track ureteric stent 

insertion, change and removal, although we recognise that at present, the 
format of such tracking systems will vary. 

3.  Human oversight of the stent database is essential at present as there is 

no standardised IT solution which will alert the clinician to an overdue stent 
exchange or removal.  Clinicians and administrative staff working within 
urology should be allocated time in their job plan to allow oversight of such 
a database, which represents a considerable amount of work. 

4.  Urologists should liaise with other colleagues who insert/manage patients 

with ureteric stents (principally radiologists, oncologists, transplant 
surgeons and gynaecologists) to ensure all patients with stents are 
monitored appropriately regardless of the clinical setting. 

Safety recommendation R/2020/092:  

It is recommended that the British Association of Urological Surgeons works with the 
Patient Information Forum to review its stent patient information leaflet. This should 
include accessibility and clinical considerations, especially with regards to side 
effects and complications, and advice on the action to take should concerns arise.  

This point has been addressed by the new BAUS patient information leaflet (PIL) 
(“Living with a stent”) published in 2022.  The PIL has been updated with all the 
relevant information regarding stent symptoms, and now includes a section at the 
back of the leaflet which is to be filled in and given to the patient upon their 
discharge.  This will provide patients with individualised information regarding their 
intended stent dwell time as well as with contact information for the relevant clinical 
team members  (Appendix 2). 

We hope that this improved PIL containing bespoke information will empower 
patients to take a role in shared-care of their stent as highlighted in the HSIB report. 

Safety recommendation R/2020/093:  

It is recommended that the British Association of Urological Surgeons provides 
guidance for staff working within the stone care pathway to promote consistent 
advice to patients as part of discharge planning. 

In addition to the standardised information about stents in the newly updated BAUS 
PILs as detailed above, we have incorporated stent information as part of the BAUS 
Endourology/NHS GIRFT acute stone pathway, which was published last year.  This 
GIRFT pathway emphasises the importance of primary treatment of obstructing 
stones unlikely to pass spontaneously (ideally within 48 hours) by means of 
extracorporeal shockwave lithotripsy (SWL) or ureteroscopy (URS).  The pathway 
contains exemplars of best practice to demonstrate how this aspirational target can 
be achieved, including utilisation of urology area networks (UANs) to ensure patients 
have rapid access to necessary treatment.  By encouraging the primary treatment of 
ureteric calculi, it is hoped that fewer “temporising stents” will be inserted in such 

 
 
 
 patients over time.  Information regarding the GIRFT acute stone pathway has been 
disseminated widely at both the Section of Endourology annual meeting in October 
2021 as well as at the main BAUS congress in 2022.  We would encourage all 
urology units to continue to develop their localised pathways using the GIRFT best 
practice examples to guide them. 

Safety recommendation R/2020/094:  

It is recommended that the British Association of Urological Surgeons encourages 
members to include information in discharge letters and other communication sent to 
GPs and patients regarding patients’ stent status, potential complications and the 
possibility of a retained stent.  

We agree with this recommendation, and we would encourage that information 
regarding stent insertion and follow up is detailed clearly in the operative record.  We 
have concerns that discharge information may already be long and complex, and 
information regarding stents is only one aspect that may need to be communicated 
to the GP.  Due to variance in hospital IT systems, it is impossible to implement a 
digital “flag” which will be applied uniformly across the NHS.   

As a minimum standard, we feel that GPs should be made aware of the following 
information on discharge letters/summaries. 

•  The reason for the insertion of the J-J stent 
•  The intended stent dwell time and whether it is intended that it will be 

removed or changed 

We would suggest that all discharge information should be copied to patients and/or 
their carers.  An example of a standardised discharge pro-forma that could be sent to 
GPs can be found in Appendix 3. 

Time will be needed for busy GPs to ensure that this information is read and 
understood, and education programmes will be needed to help GP practices 
appreciate the similarities in symptoms of UTI and those that might be more directly 
attributable to a JJ stent.     

Urinalysis (ideally formal microbiological culture rather than dipstick analysis) should 
be encouraged before patients are started on empirical antibiotics, unless they are 
febrile or otherwise systemically unwell.  

 
 We have also noted the additional safety observations in the report.  

Safety observation R/2020/073:  

The NHS Summary Care Records (SCR) system is being developed to allow for 
specific patient groups to be flagged. It may be beneficial for the British Association 
of Urological Surgeons to liaise with NHSX should opportunities arise in the future to 
use SCR to flag patients with ureteric stents to aid communication with 
primary/urgent care services.  

We agree that there is a need for a digital / technological solution for stent tracking. 
However, it is apparent that there is no immediate solution to the technical problem 
of building a system to track temporary implanted devices – extending beyond stents 
to vascular access catheters, urinary catheters etc.  

There seems to be no immediate prospect of device tracing being developed within 
the NHS, by device companies or by entrepreneurs as the practical issues are 
considerable, and the potential commercial return from developing and running such 
a system are uncertain.  

Safety observation R/2020/074:  

The National Institute for Health and Care Excellence guidance for the management 
of urinary tract infections does not include ureteric stents as a cause of urinary 
symptoms which could mimic a urinary tract infection. It may be beneficial for this 
potential complication to be considered in the next review of this and other clinical 
practice guidance.  

We agree and would be very pleased to collaborate with the authors of this 
guidance.  

 
 
 
 Conclusions 

Having taken all the above into account, we feel that the encrusted stent issue does 
not lie fully within BAUS’ remit, nor within the GIRFT Urology programme and 
therefore wish to “flag up” that the problem is complex, short of data, and remains 
unresolved, despite this timely and important HSIB report.  

We are pleased to have published the updated BAUS stent PIL and we feel that it 
provides patients with some clarity regarding stent symptoms, expected stent dwell 
time and contact details of the team responsible for management of their stent.  It is 
however contingent on members of the clinical team filling in the information 
accurately.   

Ultimately, improved information delivery will allow patients to act as equal partners 
in their stent care  and they will hopefully feel more confident to alert clinicians to 
potential stent issues including delays to removal/change. 

Importantly, we feel that clarity is needed with regard to “ownership” of the delayed 
stent removal issue, in particular as to which parts of the NHS should be taking a 
lead going forward.  As an example of this, we feel that a large part of the issue is 
fundamentally one that should sit within individual trust clinical governance systems 
and yet there are no recommendations for action by trust medical directors in the 
HSIB report.  

Finally, we suggest the following as points of action for BAUS and GIRFT to 
undertake. 

1. Basic clinical governance responsibilities mean that there is a need for GIRFT and 
BAUS to flag up that the HSIB report has highlighted that patients remain at risk. 
GIRFT and BAUS will need to write to the National Director for Patient Safety (Aiden 
Fowler). The advice would be, at the very least, to request all medical directors of 
acute trusts to ensure that they have effective stent tracking processes in place, as 
detailed above. 

2. BAUS will consider carrying out an audit of contemporary stent management 
practices. This could identify current approaches to stent tracking and attempt to 
quantify the problem of delayed removal of stents. 

3. GIRFT could enquire about medico-legal costs through the GIRFT links with NHS 
Resolution.  

4. To discuss with the Medical Device Safety Programme team how temporary 
device safety will be incorporated into their work.  

 
 
 
 
 5. BAUS may liaise with the Royal College of General Practitioners to discuss how 
information regarding stent symptoms and the importance of timely stent removal 
can best be disseminated to GPs. 

Ex-Chair BAUS Section of Endourology – 

Honorary Secretary of BAUS Section of Endourology  – 

President of BAUS –

,~1:&j 

Barking, Havering and Redbridge 
University Hospitals 
NHS Trust 

Legal Services Department 
Queen's Hospital 
Rom Valley Way, Romford, RM7 0AG 

PRIVATE & CONFIDENTIAL 

FAO: Mr G Irvine 
HM Senior Coroner 
Walthamstow Coroner's Court 
Queens Road 
London 
E17 8QP 

13th September 2022 

Dear Mr Irvine, 

Following a serious incident and review it was highlighted that Barking, Havering and  Redbridge University 
Hospitals NHS Trust (BHRUT) did not have a robust process for tracking and dealing with ureteric stents put into 
patients. This can clearly cause harm to patients. 

This led to the development and implementation of a new electronic stent register which can track and warn staff 
of stents that are about to become overdue so appropriate actions can be taken. This stent register went live in 
August 2022. 

This stent register is automatically populated when an electronic admission proforma is completed on the Trusts 
Careflow (electronic patient care) system. The system sends any patient listed for a urological stent through to 
the electronic stent register which is then monitored on a weekly basis to ensure that all patients are tracked, 
with suitable dates for removal or exchange offered. It should be noted that due to available slots these are 
sometimes beyond the normal dates for removal or exchange, but these patients remain on the stent register 
until removal or exchange.  This new system is designed to provide a robust process by which all stents will be 
properly monitored and therefore removed within appropriate timeframes going forward. 

To ensure there were no other patients with stents that were missed, the Trust committed to carrying out a 
retrospective review of all stents inserted over the preceding 3 years. This was done to ensure any patients that 
had been missed could be contacted and appropriate harm reviews carried out  so these patients can  be treated 
appropriately and as quickly as possible. To provide a robust mechanism of tracking and assurance a retrospective 
review of all stent insertions was conducted for patients attending BHRUT between 1st April 2019 and 5th August 
2022. 

 
 
 A data review was conducted of all patients on the following criteria: 

• 
• 
• 
• 
• 
• 
• 

Cystoscopy, and  insertion or exchange of stent; 
Rigid  ureteroscopy, laser stone fragmentation and stent insertion/ exchange; 
Flexible ureteroscopy, laser stone fragmentation and stent insertion/exchange; 
Ureteroscopy, biopsy and stent insertion/exchange; 
Percutaneous nephrolithotomy {PCNL) and mini PCNL; 
antegrade ureteroscopy insertion or exchange of stent; and 
antegrade stent performed by interventional radiology. 

These were then searched through the Trusts PAS system via an SQL data query and resulted in 2748 entries. 
These entries were then reviewed, and duplicate entries removed i.e. one patient record for stent insertion and 
one for removal, verified by using the NHS Number. This led to a total of 1234 patients who were under the care 
of Urology at BHRUT during the period 1st April 2019 to 5th August 2022. 

Those patients who had a stent entry but not documented removal were then cross checked to see if the stent 
should have been removed during the agreed timescale. 

Through using the above audit BHRUT has highlighted there are 23 patients that have been documented with a 
stent insertion during this time period but have not had an entry detailing a date for planned surgery. These 
patients are currently being contacted to ensure whether they have been seen at an alternative provider and a 
clinical harm review conducted if there has been a delay in surgery. They will be allocated to the next available 
date for planned surgery if appropriate. 

In addition to this process there is a drive to reduce the need for stent insertion with the introduction of a 
lithotripsy service within BHRUT. Training is planned to start in December 2022 which should reduce the number 
of patients who require the insertion of urological stents and the subsequent removal and or exchange. There has 
also been financial approval for the appointment of a third Urology Consultant to reduce the wait times for 
specialist urological opinion and subsequent surgical intervention. Currently the Job Description is with the Royal 
College for approval. 

In  respect of the Coroner's concern around the Trust's delay in identifying this as a serious incident for 
investigation, whilst a serious incident report was completed, which has resulted in key actions and 
recommendations as described above, that process should have commenced at an earlier stage and in 
accordance with the BHRUT's own governance procedures.  BHRUT has reviewed its governance procedures for 
the detection of potential incidents and via the Quality and Safety Team, the need to internally report incidents 
has been emphasised within the Divisions. In addition, BHRUT has introduced incident reporting of all new 
inquests to formalise divisional review, with the aim of capturing any incidents that may not have been incident 
reported prior to the opening of an inquest. 

BHRUT hopes that the measures described above provide reassurance in respect of the concerns raised by the 
Coroner. 

Yours sincerely, 

Chief Executive

From Neil O’Brien MP 
  Parliamentary Under Secretary of State for Primary Care and Public Health  
39 Victoria Street 
  London 
  SW1H 0EU 

Graeme Irvine 
Acting Senior Coroner  
Coroner Area of East London 
Walthamstow Coroner’s Court 
Queens Road Walthamstow 
E17 8QP  

15 February 2023 

Dear Mr Irvine,  

Thank you for your letter of 18 July 2022 about the death of Mr Graham Edgar White.  I am 
replying as Minister with responsibility for Health and Secondary Care and I thank you for 
the additional time allowed.     

Firstly, I would like to say how saddened I was to read of the circumstances of Mr White’s 
death  and  I  offer  my  sincere  condolences  to  their  family  and  loved  ones.    The 
circumstances  your  report  describes  are  very  concerning  and  I  am  grateful  to  you  for 
bringing these matters to my attention.  

In preparing this response, Departmental officials have made enquiries with NHS England 
and the Care Quality Commission. 

The  Care  Quality  Commission  (CQC)  inspected  the  Barking,  Havering  and  Redbridge 
University  Trust  in  November  2021  where  the  Urgent  Care  and  Emergency  Services 
(UEC)  at  the  Queen’s  Hospital  were  inspected.  Concerns  were  identified  and  the  Trust 
worked with local system partners to create an action plan to address these. CQC intends 
to inspect the UEC at the Queen’s Hospital again and will consider the Trust’s response to 
the  Coroner  in  these  inspection  plans.  In  the  meantime,  CQC  will  monitor  the  Trust’s 
review of this patient group through regular engagement.  

After Mr White’s death, CQC carried out an initial management review and agreed to seek 
assurance that the Trust was taking action to mitigate risk, establish oversight of patients 
with stents, and address the governance concerns regarding the escalation of the incident. 
The Trust informed CQC that they had  initially commenced a review of all 1,200 patients 
that had been fitted with a stent over the previous three years and had agreed to extend 
the review for all patients who have since had their stent removed. Early findings were that 
the COVID-19 Pandemic had impacted their oversight of this patient group.  

 
 
 
 
 
 
 
 
 
  
  
  
 
  
 Barking,  Havering  and  Redbridge  University  Trust  has  completed  a  comprehensive 
Serious  Incident/Root  Cause  Analysis  following  Mr  White’s  death.  They  have  made 
several  recommendations  including:  providing  patients  with  information  leaflets  and  stent 
cards  that  confirm  when  a  stent  should  be  taken  out  and  a  contact  number  providing  a 
direct line to the admissions office if no appointment has been confirmed within 12 weeks; 
an electronic stent register that has been operational since May 2022, providing alerts and 
prompts  to  the  service  for  timely  removal  of  stents;  the  need  for  a  standard  operating 
procedure  across  the  Trust  for  optimal  stent  management;  a  requirement  to  investigate 
non-attendance at clinics before patients are discharged; an audit of all patients with stents 
inserted  between  1  April  2019  and  31  March  2022;  to  undertake  an  assessment  of 
demand and capacity for treating stone patients; and to strengthen the process of incident 
reporting and the detection of potential incidents.  

NHS England will be working with providers, patient representatives and partners, such as 
specialist societies, to implement outcome registries across implant procedures, including 
urology  and  stent  procedures.  These  registries  will  enable  secure  patient  level  data 
collection  that  includes  the  devices  used  and  the  patient  outcomes.  They  will  improve 
device vigilance in direct care, and the monitoring of patient safety and outcomes. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.  

Yours Sincerely 

NEIL O’BRIEN MP