Recurring concern

Unsafe moving and handling of patients

First to latest report 4 Dec 2013 — 11 Jun 2025

Reports that mention this concern
20
Times this concern has been raised
23
Stated actions linked to this concern
14

What this concern includes

Includes failures of the dedicated patient moving and handling process, including moving and handling risk assessments, appropriate equipment, safe positioning or securing, and correct repositioning or transfer practices.

What is not included
  • Excludes generic staffing, training, documentation or record-keeping failures unless they are explicitly tied to the patient moving and handling process.
  • Excludes pressure-ulcer prevention and general personal-care failures that are not specifically about moving, handling, positioning or repositioning patients.
  • Excludes unrelated clinical risk assessments, including VTE, falls or malnutrition assessments, unless the assertion concerns moving and handling itself.

Reports and published responses 20 reports

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

  1. Nottinghamshire

    AI-generated summary

    Maureen POWELL · 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

    Maureen Powell died from severe frailty after a prolonged period of ill health, hospitalisation and transfer to a nursing home. A serious pressure ulcer developed and worsened in the nursing home and contributed to her death. Concerns included inadequate recording and implementation of repositioning, failure to record skin inspections, delayed equipment and specialist referral, poor record-keeping, inaccurate reporting, and insufficient communication with her family.

    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

    Failure to consistently implement repositioning

    Wider context from the report

    “1. Repositioning was undertaken, but recording and implementation was, at times, patchy; ”

    Source location

    Maureen POWELL · Prevention of Future Deaths report
    Page 1 · concerns

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The strengthened systems and procedures for monitoring residents’ care arrangements are considered appropriate in all the circumstances.

    Verbatim wording from the response

    “Accordingly, significant steps have been taken by the Home to strengthen the systems and procedures in place to monitor the correct implementation of care arrangements for residents, which are considered to be appropriate in all the circumstances.”

    Source location

    Response from Red Oaks Care Home
    Page 4 · response
    Published 19 June 2025

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Phyllis TROMANS · 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

    Phyllis Tromans, a long-term resident with Parkinson’s disease who was in a frail condition, developed a grade 4 pressure ulcer while an inpatient at Queen Elizabeth Hospital and died at Cotteridge House on 24 May 2024. Concerns included an underestimated pressure sore risk assessment, prolonged periods without repositioning, an incomplete wound care plan, and an investigation that did not establish why gaps in care had occurred.

    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

    Failure to adhere to scheduled repositioning intervals

    Wider context from the report

    “2. Mrs Tromans had a repositioning schedule in place when she was admitted to the Acute Medical Unit and subsequently to ward East Ground B. This required repositioning at no greater intervals of four hours to mitigate the risk of pressure sores. On a total of 22 occasions the schedule was not adhered to. This led to occasions where Mrs Tromans was left in the same position for up to 14 hours. ”

    Source location

    Phyllis TROMANS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver repositioning training for Tissue Viability Link Workers with therapy-team pressure mapping and safe side-lying education.

    Verbatim wording from the response

    “• Training: In December, two Tissue Viability Link Worker events focused on repositioning were held, with support from therapy teams using pressure mapping devices to identify pressure points and promote effective repositioning. The sessions also provided education on anatomy and physiology, with an emphasis on safe side-lying techniques to relieve pressure.”

    Source location

    Response from University Hospitals Birmingham
    Page 2 · response
    Published 1 November 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct weekly Acute Medical Unit repositioning audits, provide real-time feedback and reinforce schedule compliance through staff communications.

    Verbatim wording from the response

    “• Compliance Monitoring: A weekly audit of repositioning practices in the AMU is now being conducted, with real-time feedback provided to staff. The AMU also receives regular communications emphasizing the importance of following the repositioning schedule and completing daily care plans.”

    Source location

    Response from University Hospitals Birmingham
    Page 2 · response
    Published 1 November 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the Response Assessment Tool for senior-staff oversight of repositioning strategies and audit its compliance and quality.

    Verbatim wording from the response

    “• Response Assessment Tool (RAT): The Tissue Viability team has implemented the RAT to scope trust-acquired pressure ulcer events. This tool, which will be used by senior staff to ensure repositioning strategies are being followed, will be audited for compliance and quality.”

    Source location

    Response from University Hospitals Birmingham
    Page 2 · response
    Published 1 November 2024

    Open published response

  3. Berkshire

    AI-generated summary

    Wendy Ann AFFORD · 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

    Wendy Ann Afford was bedbound and living alone with a package of care before developing worsening pressure damage and an infected pressure ulcer. After hospital treatment and discharge to a care home, her health declined and she died on 15 November 2023. Concerns included inadequate skin-integrity risk assessment and monitoring, incomplete repositioning records, unclear compliance with care plans, insufficient management oversight, and possible inadequate staff training.

    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

    Incomplete recording of repositioning movements

    Wider context from the report

    “3. It was not clear whether the carers were properly following the care plan and the records showing whether or not Mrs Afford was repositioned were incomplete. The records that did exist only recorded her position or stated ‘repositioned’ they did not record whether she was moved, for example, from left to right. The facility within the electronic care record system to highlight the need for carers to reposition Mrs Afford, and record the move, were not used reliably and I heard evidence from a manager which suggested they were not aware of the ability to set repositioning as a mandatory task for each visit. ”

    Source location

    Wendy Ann AFFORD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unreliable use of electronic care-record repositioning prompts and mandatory tasks

    Wider context from the report

    “3. It was not clear whether the carers were properly following the care plan and the records showing whether or not Mrs Afford was repositioned were incomplete. The records that did exist only recorded her position or stated ‘repositioned’ they did not record whether she was moved, for example, from left to right. The facility within the electronic care record system to highlight the need for carers to reposition Mrs Afford, and record the move, were not used reliably and I heard evidence from a manager which suggested they were not aware of the ability to set repositioning as a mandatory task for each visit. ”

    Source location

    Wendy Ann AFFORD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Surrey

    AI-generated summary

    Isabella MCCREADIE · 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

    Isabella McCreadie, aged 90, suffered a fall at home causing fractures, was admitted to hospital and underwent surgery. She developed low haemoglobin, delirium and a hospital-acquired stage 4 pressure sore, and died of pneumonia at home on 6 June 2023. Concerns included insufficient dietetic staffing, pressure-sore care and training, an unprocessed dietary supplement order, and inadequate training for some agency staff using the hospital’s computer system.

    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

    Staff lacking training to support and handle patients in pain who refuse repositioning

    Wider context from the report

    “2. During evidence I was advised that a training need had been identified for staff regarding pressure sores following the passing of Mrs McCreadie. I have been advised in submissions by the hospital that they intend to address this training need by identifying e-learning staff can complete. Given in evidence it was identified that a) some staff do not know how to support and or handle patients who are in pain and refuse to be repositioned; and b) the staff are unaware of the techniques needed to be used to reposition patients who have multiple injuries, I do not consider that these can be adequately addressed by e-learning. ”

    Source location

    Isabella MCCREADIE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide in-person manual-handling induction and refresher training covering repositioning complex patients and supporting patients who resist because of pain.

    Verbatim wording from the response

    “Currently, nursing staff and healthcare support workers receive manual handling training in person on induction which provides training on how to reposition patients. This training is 4 hours on induction for any nurse or healthcare support worker with prior healthcare experience and 6 hours for anyone without prior clinical experience. Refresher training is provided online every 3 years.”

    Source location

    Response from Frimley NHS
    Page 3 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide access to Dolphin specialist mattresses with supplier training, clinical monitoring and tissue-viability referral support.

    Verbatim wording from the response

    “The Trust also now has access to a new specialist mattress called a “Dolphin” which can be used in conjunction with a tilting bed frame, designed to manage patients who find repositioning extremely painful. The ward staff receive training from the company who supply the equipment and the use of the mattress is monitored by the company with weekly visits from the supplier’s clinical adviser. There is also access to an electronic help line which can be used for any issues which arise. Staff request the dolphin mattress for patients via the Trust’s tissue viability nurse. This ensures that these patients, who are at risk of pressure injuries due to the fact they find repositioning painful, are also receiving input from the tissue viability team.”

    Source location

    Response from Frimley NHS
    Page 4 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing in-person induction and refresher training addresses repositioning complex or resisting patients, so eLearning alone is not considered adequate or necessary.

    Verbatim wording from the response

    “I do not consider that these can be adequately addressed by eLearning.”

    Source location

    Response from Frimley NHS
    Page 3 · response
    Published 6 June 2024

    Open published response

  5. East Sussex

    AI-generated summary

    Carol Ann DIVALL · 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

    Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.

    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

    Failure to provide two-hourly repositioning

    Wider context from the report

    “C. Mrs Divall developed a grade 4 sacral pressure sore. She was not referred to the Tissue Viability Nurse until 1.10.22 who confirmed in her evidence that it would have taken 12-14 days to develop and would therefore have been available to be seen by the nursing staff caring for her. Contributing to the deterioration of her pressure sore was the deflating of her hybrid mattress on at least 2 occasions. Mr Divall noticed who visited for long periods every day noticed that his wife was never repositioned as she should have been on a 2 hourly basis at any time during his daily visits. I consider that Mrs Divall's immobility and malnourishment contributed to the development of her pressure sore the care of and severity were not mentioned in the discharge summary. ”

    Source location

    Carol Ann DIVALL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Avon

    AI-generated summary

    Alan Christopher NIPPARD · 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

    Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.

    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

    Failure to use appropriate sliding sheets for repositioning

    Wider context from the report

    “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with. There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking. It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired. That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight. I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including: • That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly. • On the MAU he did not have his risk assessment done within 6 hrs as it should have been. • It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress. • Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay. • Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved. • The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed. • Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t. • On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation • Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all. • It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been. • When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly. • It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved • There was no evidence of the use of 2 sliding sheets to assist with moving him. • On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all. • Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable. • Fluid balance charts were poorly completed. • He wasn’t weighed which would have assisted with managing his oedema. • Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care. I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team. ”

    Source location

    Alan Christopher NIPPARD · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver face-to-face pressure-ulcer prevention and management training to substantive nursing, physiotherapy and occupational therapy staff.

    Verbatim wording from the response

    “Since the inquest into Mr Nippard’s death, the Tissue Viability Nursing (TVN) Team have led a programme of face to face training for all substantive members of nursing staff on Pierce Ward. In addition, all Physiotherapists and Occupational Therapists have also received training.”

    Source location

    Response from Royal United Hospitals Bath NHS Foundation Trust
    Page 1 · response
    Published 4 August 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete and monitor staff workbooks assessing knowledge and skills in pressure-ulcer prevention and management.

    Verbatim wording from the response

    “The training has focussed on addressing the learning from incidents which includes; consistently undertaking appropriate skin assessments, repositioning and the correct use of equipment. The training also incorporated training on the nationally recognised SKIN bundle which stands for ‘skin, surface, keep moving, incontinence, nutrition and hydration’ in addition to risk assessments, care planning, reporting and escalation. Staff knowledge and skills has been assessed using a workbook which has been distributed to and completed by each staff member. At the time of responding, 5 have not yet completed their work book which is being monitored and full compliance is expected.”

    Source location

    Response from Royal United Hospitals Bath NHS Foundation Trust
    Page 1 · response
    Published 4 August 2023

    Open published response

  7. North London

    AI-generated summary

    Barbara Mitchell · 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

    Barbara Mitchell died at Northwick Park Hospital on 9 July 2022 after falling at home while being assisted by a carer. The report raised concern about specialist staff training in moving and handling individuals, particularly after a fall.

    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

    Lack of specialist training for staff in moving and handling individuals after falls

    Wider context from the report

    “1. Consideration of specialist training of staff in connection with the moving and handling of individuals, especially after a fall. ”

    Source location

    Barbara Mitchell · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. North Northumberland and South Northumberland

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    Julie Elizabeth Nolan · 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

    Julie Elizabeth Nolan had underlying diabetes, hypertension, chronic kidney disease and peripheral vascular disease, and was admitted to a care home with existing pressure damage to her left foot. She later developed further pressure damage and acute osteomyelitis, deteriorated with breathing difficulties and low oxygen saturations, and died in hospital on 30 January 2022. Concerns included limited documentation of wound management and pressure care, uncertainty about whether care plans were followed, and the Manager and Registered Nurse being the designated nurse for two consecutive days.

    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

    Failure to provide wound management and repositioning in line with care plans

    Wider context from the report

    “1. The deceased was a resident in Astor Lodge Care Home. I am concerned there was limited documentation of wound management and pressure care and it is unclear the extent to which wound management and repositioning was provided in line with the care plans. ”

    Source location

    Julie Elizabeth Nolan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Suffolk

    AI-generated summary

    Colin Michael SWAIN · 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

    Colin Michael Swain was found collapsed in his front garden after drinking alcohol and was later taken to hospital following cardiac arrest and resuscitation. The inquest concluded that he died from hypoxic brain injury due to aspiration of gastric contents following alcoholic intoxication. Concerns included whether ambulance call-handling guidance adequately addressed alcohol intoxication, clearing the mouth and nose after vomiting, and turning an unconscious patient onto their back for CPR.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Potentially unsafe supine positioning of unconscious patients after vomiting

    Wider context from the report

    “(3) Whether turning an unconscious patient onto their back after vomiting is good practice, in the absence of clinician support ”

    Source location

    Colin Michael SWAIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. East London

    AI-generated summary

    Robert Walaszkowski · 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

    Robert Walaszkowski, a detained mental health patient, sustained head and cervical spine injuries after likely colliding with a locked door and later died from catastrophic cervical spine, vertebral artery and hypoxic brain injuries on 15 November 2019. Concerns included excessive lorazepam dosing, failure to perform a cervical spine CT scan and full medical assessment before discharge, and his transfer in an unsuitable vehicle without support or restraints while in very poor physical condition. The inquest heard that placing detained mental health patients on the floor of secure vans appeared to be an accepted practice, and the jury concluded that his death was contributed to by neglect.

    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

    Failure to secure patients safely in the transport vehicle

    Wider context from the report

    “It is of concern that: (i) There was no review by Patient Transport UK Ltd into the service provided to Robert in the early hours of 20 October 2019. (ii) The apparently trained transport staff did not re-consider the appropriateness of the vehicle when they observed Robert’s very low level of consciousness and his inability to walk; sit unaided and hold his head upright. (iii) The staff placed Robert, in this concerning condition, on the floor of the vehicle without any seat belt or other mechanism to keep him safe and secure. (iv) Placing mental health patients on the floor of the caged area, seems to be an accepted practice by Patient Transport UK Ltd. ”

    Source location

    Robert Walaszkowski · 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