First reported 29 Sep 2013•Latest report 19 Dec 2025
Definition
What this concern includes
Includes failures of controls dedicated to managing deteriorating wounds, such as wound assessment, monitoring, documentation, treatment, communication, specialist referral, follow-up and escalation, where the reports support their connection to wound management.
Not included
Excludes generic failures in escalation, communication, training, staffing or documentation that are not specifically tied to wound management.
Excludes unrelated safety systems, hazards and clinical conditions without a material wound-management component.
Excludes isolated failures concerning stable wounds where deterioration or the risk of deterioration is not part of the reported unsafe condition.
Reports
11
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
44
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Care Quality Commission4
NHS Greater Manchester Integrated Care Board2
Barchester Healthcare Limited1
Beech Dene Residential Care Home1
Central and North West London NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Department of Health and Social Care1
Fernlea1
Leek Health Centre1
Litch Care Services Limited1
Meanwood Group Practice1
Midlands Partnership University NHS Foundation Trust1
National Institute for Health and Care Excellence1
NHS Wales Shared Services Partnership1
Office of the Chief Coroner1
Health and social care service regulator4
NHS trust3
Healthcare site2
Integrated care board2
Residential care home2
Type not available2
Coronial office1
Domiciliary care provider1
Executive non-departmental public body1
Health professional body1
Health-system partnership1
Local health board1
Ministerial department1
Private limited company1
Trade union and professional body1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Surrey
Concerns raised1
Failure to provide appropriate pressure sore treatment
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11
Action
Introduce and embed the Enable electronic records and case-management system for care documentation and oversight.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Deliver reflective sessions and disseminate inquest learning to Home staff on pressure-injury risk, prevention, treatment and documentation.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Deliver staff training, supervision, knowledge checks and refresher sessions on pressure-area care, tissue-viability policy, risk assessment, prevention, skin monitoring, wound treatment and record keeping.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Provide weekly Clinical Development Nurse reviews of skin-integrity risks, care plans, wound assessments, categorisation, referrals and clinical concerns.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Operate daily, monthly and bi-monthly audits of care documentation, skin integrity, risk assessments, equipment, interventions and follow-up actions.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Provide dedicated management and clinical support, daily meetings and escalation of changes in residents’ clinical status through electronic notifications.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Continue monitoring the safety and quality of care at Windmill Manor.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
Action
Consider whether criminal enforcement is appropriate in this case.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
Action
Deliver pressure-area, wound-management, tissue-viability, risk-assessment, prevention, skin-monitoring and record-keeping training with supervision and knowledge checks for staff.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Provide ongoing weekly Clinical Development Nurse reviews of skin-integrity risks, wound assessments, categorisation and care plans.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
Action
Maintain electronic notifications and management oversight of clinical-status changes, wound categorisation, care planning and treatment regimes.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The registered provider is legally responsible for ensuring service users receive safe care and treatment, including pressure wound care.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised1
Failure to escalate concerns about deteriorating wounds
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Use a detailed wound-care template for relevant consultations, including four-week completion and photographic documentation.
Stated by Meanwood Group PracticeStated completedThe respondent said that this action was complete when they made their response on 11 December 2024.
Action
Update GP and practice nursing knowledge, training and wound-care processes in line with Leeds guidelines.
Stated by Meanwood Group PracticeStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2024.
Action
Audit patients receiving regular practice wound care monthly, moving to three-monthly audits once the system is assured.
Stated by Meanwood Group PracticeStated completedThe respondent said that this action was complete when they made their response on 11 December 2024.
Action
Adopt four-week escalation triggers for non-improving foot and leg wounds, including podiatry or Tissue Viability referral consideration.
Stated by Meanwood Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 11 December 2024.
Action
Hold regular multidisciplinary discussions for complex or non-healing wounds and record outcomes in patient records.
Stated by Meanwood Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 11 December 2024.
Devon, Plymouth and Torbay
Concerns raised2
Delays in moving patients to prevent pressure sore deterioration
Failure to photograph wounds to monitor progression or deterioration
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review reported tissue-damage incidents, take immediate local learning actions, and assess implications for the Trust-wide improvement plan.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2025.
Action
Establish a Northern-site leadership workstream to strengthen front-line nursing practice in pressure-ulcer prevention and management, with senior oversight of delivery.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing Trust-wide pressure damage prevention arrangements provide sufficient assurance that further work and dissemination are not required.
Stated by Royal Devon University Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised3
Lack of a communication strategy supporting joint working and family involvement in pressure-ulcer care
Failure to provide the GP with sufficient information about pressure-ulcer deterioration
Failure to share and discuss internal pressure-ulcer reviews with the family
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Develop an information leaflet explaining how families can contact District Nursing for pressure-area-care advice.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Include joint-working Quality Statements in the service’s next assessment and follow up actions addressing previously identified communication shortfalls.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Follow up the registered manager’s investigation into failures to keep families informed and seek assurance that resulting actions mitigate communication risks.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Discuss with the nursing team the importance of following up concerns and actions directly with GPs rather than relying on care-home staff.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.
Action
Follow up actions establishing clear responsibility for escalating wound-care concerns to GPs.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Ensure a Being Open discussion occurs with patients or families after all rapid reviews deemed to involve no lapses in care, with compliance monitored monthly.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The care home provider is responsible for keeping family members updated about residents’ health, including pressure ulcer management and nursing advice.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The registered GP had access to current District Nursing information through the shared electronic record, contrary to the concern that information was unavailable.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The GP could reasonably expect tissue viability specialists to lead pressure-ulcer treatment and advise the GP if treatment became ineffective.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The review panel found no District Nursing care lapses that directly contributed to the acquired pressure ulcers.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Sefton St Helens & Knowsley
Concerns raised1
Failure to inform appropriate clinical and social care services of pressure injuries
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Lack of wound treatment assessment charts
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide additional wound-care documentation training and verify staff completion through training-register checks.
Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
Action
Audit nursing documentation and pressure-ulcer management, using a developed audit tool and reporting findings to senior management.
Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Records show wound assessments occurred after 18 December 2018, consistent with the Trust’s fortnightly assessment guidance.
Stated by Midlands Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing NICE guidance, local NHS policies and the emergency department safety checklist provide relevant arrangements for preventing and managing pressure ulcers.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised3
Failure to recognise and escalate significant pressure-ulcer deterioration promptly
Failure of pressure-ulcer forms to capture deterioration and require detailed monitoring
Lack of a system to follow up unanswered specialist referrals
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11
Action
Provide wound-management refresher training to registered nurses and care staff.
Stated by Olea Care LtdStatus at responseThe respondent said that this action was partly complete when they made their response on 31 December 2019.
Action
Embed React to Red wound-management training in induction for all new staff.
Stated by Olea Care LtdStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Route tissue-viability referrals by email or telephone, confirm them by summary email and next-day calls, and track follow-up using diary and audit-sheet prompts.
Stated by Olea Care LtdStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Notify the GP of all tissue-viability referrals and include wound management in weekly GP ward rounds.
Stated by Olea Care LtdStated plannedThe respondent said that this action was planned when they made their response on 31 December 2019.
Action
Implement electronic pressure-ulcer photography at identification and regular intervals to monitor deterioration.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Change Tissue Viability referrals from fax to email and add prompts to follow up referrals not actioned within two working days.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2019.
Action
Adopt the NHS wound-management document within the Quality Management System.
Stated by Olea Care LtdStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Implement an electronic care-planning system that uploads information and photographs in real time.
Stated by Olea Care LtdStated plannedThe respondent said that this action was planned when they made their response on 31 December 2019.
Action
Adopt the Stockport pressure-ulcer monitoring form for consistent, regular monitoring.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Require Fernlea staff to obtain email read receipts, telephone the service the following day, and record confirmed visit dates.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Inner North London
Concerns raised1
Lack of clear escalation instructions for worsening open wounds
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Apply the Lower Limb and Leg Ulcer Management Policy to standardize wound management and escalation across the Trust.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Reinforce the wound policy, escalation responsibilities, emergency-services role, qualified-nurse attendance, reassessment, and risk-factor management with the involved team.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Hold a follow-up meeting to assess embedded learning and systematic identification of deteriorating patients at handovers.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Oversee reassessment of wound-care competence for all relevant staff.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Cascade a Trust-wide clinical message reminding community nursing teams about wound policy, consent, capacity, and escalation requirements.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Share case learning through the clinical-message process, a learning event, and the Pressure Ulcer Board.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Retrain team members to use the NEWS2 tool for identifying deterioration and seeking emergency help.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
Delays in Tissue Viability Nurse and wound care input
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of controls dedicated to managing deteriorating wounds, such as wound assessment, monitoring, documentation, treatment, communication, specialist referral, follow-up and escalation, where the reports support their connection to wound management.
