Recurring concern

Inadequate wound management for deteriorating wounds

First to latest report 29 Sep 2013 — 19 Dec 2025

Reports that mention this concern
11
Times this concern has been raised
16
Stated actions linked to this concern
44

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.

What is 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 and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Dorothy Townley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dorothy Townley sustained burns after spilling tea at home on 28 September 2012; the burns became infected and she was admitted to hospital on 11 October. Despite active treatment, she died on 20 October 2012. Concerns included communication between District Nurses and the GP, limited knowledge and training in burn treatment, inadequate wound assessment documentation, and unclear processes for requesting urgent blood tests.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate detail in wound assessment charts for burns

    Wider context from the report

    “3. The wound assessment chart did not assist as it was not as detailed as it should be for burns in order to help chart their progress or deterioration. ”

    Source location

    Dorothy Townley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026