Recurring concern

Inadequate management of burns

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First reported 9 May 2018•Latest report 13 Feb 2024

Definition

What this concern includes

Includes failures of controls specifically dedicated to managing burns, including burn-related recognition, urgent escalation or referral, first aid, treatment guidance, and communication of burn-care requirements.

Not included

Excludes generic staffing, training, documentation or communication deficiencies unless the report directly ties them to a dedicated burn-care control.
Excludes unrelated temperature-monitoring, referral, escalation or clinical-care failures not specifically concerning burns.
Excludes deficiencies concerning prevention of unrelated heat or thermal hazards rather than care after a burn injury.

Reports: 2
Individual concerns: 3
Date range: 2018–2024
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1

Chelsea and Westminster Hospital1

Colton Lodges Care Home1

Hc-One Limited1

Individual (care of Medical Protection Society)1

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.

13 Feb2024
West Yorkshire (Eastern)
Concerns raised1
1. Failure to adequately convey and proactively flag the importance of cooling burns by running water to nursing staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Develop a staff guide covering burns and scald management, including alternatives when running water is unavailable or impractical.
  Stated by Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, LeedsStated completed
2. Action
  Develop training on managing burns and scalds.
  Stated by Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, LeedsStated completed
3. Action
  Make burns and scalds training available on the local staff training site.
  Stated by Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, LeedsStated planned
1. Action
  Develop procedural guidance on common injuries, including burns and scalds for people cared for in bed.
  Stated by Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, LeedsStated in progress
AI-generated summary

Blanche Audrey Knowles · 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

Blanche Audrey Knowles, who had multiple health conditions and was receiving nursing care, suffered burns when an inadequately checked hot drink spilled into her lap. She later became frail and died on 1 September 2023; the burns contributed to her death. The principal concern was that staff had not been adequately informed or trained about cooling burns under running water.

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 adequately convey and proactively flag the importance of cooling burns by running water to nursing staff
Wider context from the report
“Whilst it was clear from the written and oral evidence provided to the inquest that measures had been implemented to address the risks from hot drinks, for example by the purchase and use of thermometers, upon questioning, the matter of the importance of assisting an individual who has suffered burns by way of ‘cooling by running water’ as noted by the Ambulance staff did not appear to have been adequately conveyed to staff, be that through training or by way of clear communication as operational matters/requirements in the nursing care context. The burns suffered by Blanche contributed to the cause of her death and whilst it was not established that the recorded failure to apply ‘cooling by running water’ to her injuries would have made a material difference, I remain concerned that the clear importance of applying ‘cooling by running water’ does not appear to be proactively flagged in relevant policies/procedures or by active practical/operational communications to staff. ”
Source location
Blanche Audrey Knowles · 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
Develop a staff guide covering burns and scald management, including alternatives when running water is unavailable or impractical.

Verbatim wording from the response
“• We have developed a ‘Here’s How To’ guide for our staff based on best practice guidance which includes references to current NHS and NICE guidance, including guidance on the use of cool wet towels and compresses if running water is not available or where a person is being nursed and cared for in bed where the risk of moving them is higher than cooling the burn or scald with cool wet towels or compresses.”

Source location
Response from HC-One
Page 1 · response
Published 21 February 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
Develop training on managing burns and scalds.

Verbatim wording from the response
“• We have developed training on the management of burns and scalds which will be available on our local staff training site, (Touchstone).”

Source location
Response from HC-One
Page 2 · response
Published 21 February 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
Make burns and scalds training available on the local staff training site.

Verbatim wording from the response
“• We have developed training on the management of burns and scalds which will be available on our local staff training site, (Touchstone).”

Source location
Response from HC-One
Page 2 · response
Published 21 February 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
Develop procedural guidance on common injuries, including burns and scalds for people cared for in bed.

Verbatim wording from the response
“• We are developing procedural guidance on common injury types, which will include management of burns and scalds, including people who are nursed and cared for in bed.”

Source location
Response from HC-One
Page 2 · response
Published 21 February 2024
Open published response
9 May2018
Inner South London
Concerns raised2
1. Failure to provide advice to return to hospital after reported high temperature following a burn
2. Failure to trigger urgent hospital referral for high temperature following a burn
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Alert the Paediatric Burns Network to the advice so that improvements can be made more widely.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated completed
Respondent positions 3
1. Position
  There was no suggestion that a temperature spike was mentioned during the telephone call and then not recorded or acted upon.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustDisputes the concern
1. Position
  The existing national leaflet already provides nationally accepted burns advice, correct warning signs, and appropriate instructions for parents seeking further care.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustExisting arrangements considered sufficient
2. Position
  The burns unit can already be contacted by telephone 24 hours a day, every day.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Edward Joyce · 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

Edward Joyce suffered an accidental scalding injury on 19 November 2017 and later developed septic shock from infected burns. He became severely unwell on 22 November and died despite attempts at resuscitation. Concerns included that a temperature of 38.9°C did not trigger an urgent hospital referral and was not recorded when his mother telephoned the hospital, and that parents were not advised to bring him back to hospital.

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 advice to return to hospital after reported high temperature following a burn
Wider context from the report
“The evidence at the inquest was that a temperature reading above 38°C following a burn to a young child is highly concerning, and could be an early sign of septicaemia and toxic shock syndrome. (1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital. (2) Eddie’s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital. (3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and availability of a 24 hour telephone advice from the burns unit. ”
Source location
Edward Joyce · 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
Failure to trigger urgent hospital referral for high temperature following a burn
Wider context from the report
“The evidence at the inquest was that a temperature reading above 38°C following a burn to a young child is highly concerning, and could be an early sign of septicaemia and toxic shock syndrome. (1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital. (2) Eddie’s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital. (3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and availability of a 24 hour telephone advice from the burns unit. ”
Source location
Edward Joyce · 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
Alert the Paediatric Burns Network to the advice so that improvements can be made more widely.

Verbatim wording from the response
“With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.”

Source location
2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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
There was no suggestion that a temperature spike was mentioned during the telephone call and then not recorded or acted upon.

Verbatim wording from the response
“It is the Trust’s understanding that the evidence from Nurse ████████ explained the action that would have been taken if a spike in temperature was mentioned during the relevant telephone call but there was no suggestion that a spike in temperature was mentioned and not recorded / acted on.”

Source location
2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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
The existing national leaflet already provides nationally accepted burns advice, correct warning signs, and appropriate instructions for parents seeking further care.

Verbatim wording from the response
“With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.”

Source location
2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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
The burns unit can already be contacted by telephone 24 hours a day, every day.

Verbatim wording from the response
“With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.”

Source location
2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to adequately convey and proactively flag the importance of cooling burns by running water to nursing staff

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.4

Concerns raised2

Failure to provide advice to return to hospital after reported high temperature following a burn

Failure to trigger urgent hospital referral for high temperature following a burn

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 4

Actions described in response 1

Respondent positions 3