Recurring concern

Unsafe provision and use of pressure-relief seat cushions

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First reported 7 Mar 2022•Latest report 24 Jul 2023

Definition

What this concern includes

Includes failures of dedicated pressure-relief seat-cushion controls, including provision of use instructions, attachment or securing to wheelchair or chair surfaces, selection, availability and implementation of required seated pressure relief.

Not included

  • Excludes broader pressure-injury prevention, repositioning, skin assessment or nursing-care failures where no pressure-relief seat-cushion control is identified.
  • Excludes generic equipment-maintenance or seating failures unrelated to pressure-relief cushions.
  • Excludes failures concerning mattresses, bed-based pressure relief or other pressure-management equipment unless the assertion also concerns a pressure-relief seat cushion.
  • Excludes generic patient or staff information failures unless they directly affect safe use of a pressure-relief seat cushion.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2022–2023

First to latest report issue date

Stated actions
2

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.

Royal United Hospital1
Royal United Hospitals Bath NHS Foundation Trust1
Surrey Downs Tissue Viability and Lymphoedema Service1
Tadworth Grove Care Home1

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. 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 provide seated pressure relief

    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

  2. Surrey

    AI-generated summary

    Michael John Humphries · 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

    Michael John Humphries, who was quadriplegic and diabetic, was admitted to hospital on 20 March 2019 with severe sepsis and died on 30 March 2019 after being placed into palliative care. Concerns included the lack of information about the proper use of a Tbar cushion, inadequate wound-care knowledge and documentation, limited access to suitable dressings, and an ineffective initial referral process to tissue viability nurses.

    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 information on proper use of Tbar cushions

    Wider context from the report

    “1. Tbar cushion arrived with Michael without any information on its proper use. 2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound. 3. Wound care knowledge was not adequate. 4. Provision of correct dressings not available to non-TVN professionals. 5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care. 6. Information may be useful to National Wound Care Strategy. ”

    Source location

    Michael John Humphries · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
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Data last updated 7 September 2026