Recurring concern

Inadequate wound management for deteriorating wounds

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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

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.

  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
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Data last updated 7 September 2026