Recurring concern
Inadequate district nursing wound care
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Request correctionFirst reported 7 Aug 2013•Latest report 20 Aug 2025
What this concern includes
Includes failures of the district nursing wound-care process, including inadequate assessment or documentation, referrals, attendance frequency, dressing changes, coordination, escalation or other controls specifically required to deliver safe wound care.
Not included
- Excludes generic failures to record visits or clinical information that are not specifically tied to district nursing wound care.
- Excludes general district nursing capacity or communication problems unless they directly impair wound care.
- Excludes non-district-nursing wound care and unrelated discharge, referral or record-keeping deficiencies.
- Reports
- 17
- Individual concerns
- 23
- Date range
- 2013–2025
- Stated actions
- 25
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to provide district nursing wound care at appropriate frequency
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 concernsEach 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.3
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Action
Individualise daily district-nursing visit allocations for patients’ pressure-ulcer management needs, with monthly service-lead oversight.
Stated by Whittington Health NHS Trust -
Action
Include tissue-viability referrals, recommendation adherence and pressure-ulcer improvement-plan progress in quarterly audits and divisional quality review.
Stated by Whittington Health NHS Trust -
Action
Trial visit-allocation software in the urgent-response team to assess whether it can reduce travel time and increase visit time.
Stated by Whittington Health NHS Trust
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Concerns raised1
Limited access to tissue viability and district nursing information and support for wound care in the community
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 concernsEach 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.3
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Position
Demand across Greater Manchester tissue viability and district nursing services made improved community wound-care access difficult to achieve.
Stated by NHS Greater Manchester Integrated Care Board
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Position
Limited access to community tissue viability and district nursing wound care falls outside the regulator’s remit.
Stated by Care Quality Commission -
Position
The Secretary of State and Greater Manchester Integrated Care are considered better placed to address limited community wound care access.
Stated by Care Quality Commission
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Concerns raised3
Failure to escalate pressure-wound issues to other services and professionals when needed
Failure to provide appropriate pressure-wound offloading advice and recommendations to families and carers
Uncompleted pressure-wound safety protocols
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 concernsEach 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.3
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Action
Review and update SystmOne wound assessments and care plans to include photography, heel off-loading advice and onward-referral guidance.
Stated by County Durham and Darlington NHS Foundation Trust -
Action
Deliver community nursing study days covering updated wound documentation, equipment, incident reporting and heel off-loading.
Stated by County Durham and Darlington NHS Foundation Trust -
Action
Develop patient and carer information leaflets about heel off-loading.
Stated by County Durham and Darlington NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Implemented and planned measures are considered sufficient to address concerns about learning, offloading advice, and escalation.
Stated by County Durham and Darlington NHS Foundation Trust
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Concerns raised1
Failure to upload updated images for Tissue Viability review of deteriorating pressure ulcers
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 concernsEach 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.1
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Action
Photograph and upload every wound to the patient’s electronic record weekly.
Stated by NHS Greater Manchester Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
It is unclear whether updated tissue-viability advice would have altered treatment, although providing an updated image would have been helpful.
Stated by Care Quality Commission
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Concerns raised1
Failure to maintain adequate wound inspections and dressing changes when diabetic foot clinic attendance changes
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 concernsEach 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
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Action
Continue participating in monthly multidisciplinary meetings with clinical, social care, mental health, palliative care and pharmacy professionals.
Stated by Tower Bridge Care Centre -
Action
Review each resident’s clinical risks through monthly Key Clinical Indicators exception reports, including wounds and escalation processes.
Stated by Tower Bridge Care Centre
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
There is no evidence that clinic attendance was less frequent than clinically indicated or reduced because of the Covid-19 pandemic.
Stated by King'S College Hospital NHS Foundation Trust
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Position
The Home disputes that the GP was unaware of the reduced clinic attendance or wound-dressing changes, stating the GP was informed.
Stated by Tower Bridge Care Centre
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Concerns raised1
Failure to take wound photographs for continuity and reference
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to make immediate tissue viability referrals for category 3 pressure ulcers
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 concernsEach 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
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Action
Review the referral process for Tissue Viability Nursing referrals.
Stated by Whittington Health NHS Trust -
Action
Revise and formally ratify Tissue Viability Nursing referral guidance, following staff consultation, with regular compliance audits.
Stated by Whittington Health NHS Trust
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Concerns raised1
Failure to make district nurse referrals for specialist wound care
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of district nurses to involve Tissue Viability Nurses
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 concernsEach 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
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Position
District nurses are skilled in wound management and refer to tissue viability specialists when wounds deteriorate, consistent with Trust policy.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised2
Failure to photograph leg wounds for assessment
Lack of an updated care plan for leg dressings
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026