An inquest has heard how 87-year-old Sylvia Macknay died shortly after being found with 2 litres of urine in her catheter bag.
The tragic incident occurred at Care UK’s Haven Lodge care home in Clacton-on-Sea in Essex in September.
Inquest coroner Caroline Beasley-Murray told Mrs Macknay’s family: “This is a very sad case.
“Not only have you lost your mother you have had the ordeal of being at this inquest. She sounded the most interesting lady.”
Mrs Macknay had been admitted to the home after suffering a stroke in June. She was found suffering discomfort when she was visited by her daughter on 3 September.
After having her catheter drained, Mrs Macknay was admitted to Colchester General Hospital but died shortly afterwards.
Her cause of death was recorded as bronchopneumonia and urinal sepsis.
Care UK Regional Director Bernard Mawoyo said: “We would like to again offer our sincere condolences to the family of Mrs Macknay. We accept that sadly, on that one day, checks and record keeping on Mrs Macknay’s catheter and urine output were not carried out according to our standard procedures.
“Since then, we have worked closely with the CQC to develop and implement an improvement plan to minimise the chances of anything like this ever happening again. It was pleasing to see that the coroner described this plan as ‘eminently sensible’ and recognised that we are very happy to work with the CQC to ensure these changes are embedded.
“As a result of Mrs Macknay’s death, all care and nursing colleagues in the home took part in refresher training on catheter care and maintenance and the importance of accurately recording fluid intake and urine production for residents fitted with catheters. Earlier this year, catheter care in the home was audited by inspectors from the Care Quality Commission and their report shows that they were reassured by what they found.”