Recurring concern

Unreliable referrals to tissue viability services

First to latest report 7 Aug 2013 — 11 Jun 2025

Reports that mention this concern
13
Times this concern has been raised
19
Stated actions linked to this concern
10

What this concern includes

Includes failures in recognising when tissue viability input is needed, applying referral criteria, selecting and routing the referral, completing or tracking it, and escalating or arranging timely specialist involvement.

What is not included
  • Excludes general wound assessment, treatment, monitoring or follow-up failures where tissue viability referral is not the deficient control.
  • Excludes shortages or unavailability of tissue viability staff or services where the referral process itself is reliable.
  • Excludes failures to follow tissue viability advice after specialist involvement has been obtained.
  • Excludes generic referral, communication, documentation or training deficiencies unless they directly impair referral to tissue viability services.

Reports and published responses 13 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

    Delays in referral to tissue viability services

    Wider context from the report

    “7. The referral to tissue viability was made too late as it occurred after the wound had got beyond the ability of the in-house nursing staff to manage and treat the wound; ”

    Source location

    Maureen POWELL · 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

    Conduct weekly and monthly management audits of pressure-care records, actions, professional input, care plans and risk assessments.

    Verbatim wording from the response

    “• Weekly and monthly audits are conducted by management in relation to care records relating to residents’ pressure care and skin integrity, for the purpose of ensuring that all actions have been completed in a timely manner, any external professional input required has been sought accordingly, and that care plans and risk assessments have been reviewed and updated as appropriate.”

    Source location

    Response from Red Oaks Care Home
    Page 2 · response
    Published 19 June 2025

    Open published response

  2. West Yorkshire Eastern

    AI-generated summary

    Karen Lesley Day · 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

    Karen Lesley Day sustained a leg laceration in 2021 and received care from her GP practice and district nursing team. She was later admitted to hospital extremely unwell, did not respond to active treatment, and died on 14 July 2022. Concerns were raised that the lower limb framework was not followed consistently, referrals and escalation were inadequate, and the practice lacked adequate systems for timely internal investigation of patient safety incidents.

    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 make appropriate tissue viability referrals

    Wider context from the report

    “(1) During the course of the inquest I heard evidence that the GP practice did not follow the lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate concerns around the deteriorating wound or consider appropriate measures to support the deceased to either self-manage her wound with an at home compression bandaging kit, or to support her to attend appointments on a more regular basis. I am concerned that the practice was unable to provide assurance that the same situation could not occur again. ”

    Source location

    Karen Lesley Day · 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

    Review the Tissue Viability referral process to prevent inappropriate rejection of referrals.

    Verbatim wording from the response

    “Following the inquest the case was discussed again at a practice meeting on 2nd December 2024 with all partners, salaried GPs and GP registrars, practice manager and deputy, practice nurse lead and reception manager and a full significant event analysis was presented and discussed. This led to the use of a detailed wound care template for all relevant wound management consultations, a review of the use of Tissue Viability Team referral process to ensure no other referrals are rejected, and GPs and the practice nursing team updating their knowledge, training and processes for wound care, in line with Leeds guidelines.”

    Source location

    Response from Meanwood Group Practice
    Page 1 · response
    Published 11 December 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

    Update GP and practice nursing knowledge, training and wound-care processes in line with Leeds guidelines.

    Verbatim wording from the response

    “Following the inquest the case was discussed again at a practice meeting on 2nd December 2024 with all partners, salaried GPs and GP registrars, practice manager and deputy, practice nurse lead and reception manager and a full significant event analysis was presented and discussed. This led to the use of a detailed wound care template for all relevant wound management consultations, a review of the use of Tissue Viability Team referral process to ensure no other referrals are rejected, and GPs and the practice nursing team updating their knowledge, training and processes for wound care, in line with Leeds guidelines.”

    Source location

    Response from Meanwood Group Practice
    Page 1 · response
    Published 11 December 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

    Audit patients receiving regular practice wound care monthly, moving to three-monthly audits once the system is assured.

    Verbatim wording from the response

    “• To audit all patients receiving regular wound care within the practice every month, and once the system is assured every 3 months.”

    Source location

    Response from Meanwood Group Practice
    Page 2 · response
    Published 11 December 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

    Adopt four-week escalation triggers for non-improving foot and leg wounds, including podiatry or Tissue Viability referral consideration.

    Verbatim wording from the response

    “• The practice will adopt a process that all foot wounds that have shown no improvement or are static within four weeks would trigger a review and referral to podiatry and all leg wounds that have shown no improvement should be reviewed and considered for referral to the Tissue Viability service.”

    Source location

    Response from Meanwood Group Practice
    Page 2 · response
    Published 11 December 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

    Hold regular multidisciplinary discussions for complex or non-healing wounds and record outcomes in patient records.

    Verbatim wording from the response

    “• We will hold regular multi-disciplinary team discussions for patients with complex or wounds that are failing to heal. The lead nurse to bring forward patients the nurses are concerned about. The result of the MDT will be recorded in the patient’s record.”

    Source location

    Response from Meanwood Group Practice
    Page 2 · response
    Published 11 December 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

    Long-term wound care will be referred to specialist services, with the ICB expected to commission the necessary service.

    Verbatim wording from the response

    “• The practice will inform the ICB in Leeds of its intention to no longer provide long-term wound care management and would refer all relevant patients to a specialist service for wound care management. The practice would expect the ICB to commission the necessary service.”

    Source location

    Response from Meanwood Group Practice
    Page 3 · response
    Published 11 December 2024

    Open published response

  3. 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

    Delays in referral to tissue viability specialists

    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

    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

    Undertake a pressure-ulcer prevention and management quality-improvement project with Tissue Viability Team support.

    Verbatim wording from the response

    “In order to strengthen the approach regarding managing pressure sores, the Tissue Viability Team are supporting the ward to undertake a quality improvement (QI) project in relation to the prevention and management of pressure ulcers including the recognition of potential skin damage likely to deteriorate. This is especially relevant to patients who have a history of trauma which often incorporates frailty, poor health and a long lie prior to their admission to the ward. The success of the interventions on this QI project to reduce pressure ulcers in the unit will be reviewed and recommendations extended across the organisation in all wards.”

    Source location

    Response from East Sussex Healthcare
    Page 3 · response
    Published 15 May 2024

    Open published response

  4. Inner North London

    AI-generated summary

    Cecilia EDWARDS · 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

    Cecilia Edwards was admitted to Whittington Hospital on 26 September 2020 with a severe right elbow infection and died there two weeks later. The report identified concerns that a category 3 pressure ulcer was not referred promptly to a tissue viability nurse, that many visiting nurses were agency staff without clear protocols, and that nursing visits were not routinely coordinated with carers, resulting in incomplete care on some occasions.

    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 make immediate tissue viability referrals for category 3 pressure ulcers

    Wider context from the report

    “1. On 12 February 2020, a district nurse assessed Ms Edwards’ elbow as a category 3 pressure ulcer, which should have prompted an immediate referral to the tissue viability nurse. However, no such referral was made, either by the attending nurse; the district nurses who visited twice a week over the next seven months; the frequent care plan reviewers; or the shift co-ordinator until 22 September 2020. ”

    Source location

    Cecilia EDWARDS · 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

    Review the referral process for Tissue Viability Nursing referrals.

    Verbatim wording from the response

    “Whittington Health has reviewed the process for referral to the Tissue Viability Nursing service (TVN) and is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, and not purely based on categorisation alone. The new guidance will undertake regular audit practice to monitor compliance. The guidance will be formally ratified in August 2021, following consultation with staff.”

    Source location

    2021-0049-Response-from-Whittington-Hospital-Redacted
    Page 1 · response
    Published 26 February 2021

    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

    Revise and formally ratify Tissue Viability Nursing referral guidance, following staff consultation, with regular compliance audits.

    Verbatim wording from the response

    “Whittington Health has reviewed the process for referral to the Tissue Viability Nursing service (TVN) and is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, and not purely based on categorisation alone. The new guidance will undertake regular audit practice to monitor compliance. The guidance will be formally ratified in August 2021, following consultation with staff.”

    Source location

    2021-0049-Response-from-Whittington-Hospital-Redacted
    Page 1 · response
    Published 26 February 2021

    Open published response

  5. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Mavis May Lawrence · 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

    Mavis May Lawrence, who had severe dementia and required full nursing care, was admitted to hospital with dehydration, deep ungradable pressure sores and a buttock abscess, and later died on 28 February 2019. The inquest concluded that she died from natural causes exacerbated by infected pressure sores. Concerns included gaps in pressure-area checks and care documentation, a pressure mattress being turned off, lack of escalation and pain-relief evidence, insufficient GP involvement, and district nurses not involving 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

    Failure of district nurses to involve Tissue Viability Nurses

    Wider context from the report

    “(8) District nurses had not involved Tissue Viability Nurses. ”

    Source location

    Mavis May Lawrence · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    District nurses are skilled in wound management and refer to tissue viability specialists when wounds deteriorate, consistent with Trust policy.

    Verbatim wording from the response

    “(8) District nurses had not involved Tissue Viability Nurses. The district nurses and assistant practitioner band 4 assistant practitioners are skilled in managing wounds; including pressure ulcers.”

    Source location

    2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
    Page 2 · response
    Published 26 November 2020

    Open published response

  6. Shropshire, Telford and Wrekin

    AI-generated summary

    Peter SUDLOW · 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

    Peter SUDLOW developed a sacral pressure sore during a hospital admission following ischaemic myelopathy and paraplegia. The sore deteriorated, became infected, and he later died in a hospice on 8 April 2019. Concerns included failures to refer to the Tissue Viability Nurse at relevant stages and a lack of clear guidance on referrals, pressure sore prevention, and the relationship with Waterlow scores, particularly for patients with paraplegia or neurological deficits.

    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 refer patients to the Tissue Viability Nurse at indicated pressure-ulcer risk or severity points

    Wider context from the report

    “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time. (2) There was no referral to the TVN when the sore was categorised as a grade 2. (3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17. (4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19. (5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made. (6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores. (7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit. (8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff. (9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3. ”

    Source location

    Peter SUDLOW · 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

    Lack of guidance on Tissue Viability Nurse referrals for patients with paraplegia or neurological deficit

    Wider context from the report

    “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time. (2) There was no referral to the TVN when the sore was categorised as a grade 2. (3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17. (4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19. (5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made. (6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores. (7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit. (8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff. (9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3. ”

    Source location

    Peter SUDLOW · 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

    Lack of clear guidance on when and in what circumstances to refer patients to the Tissue Viability Nurse

    Wider context from the report

    “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time. (2) There was no referral to the TVN when the sore was categorised as a grade 2. (3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17. (4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19. (5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made. (6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores. (7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit. (8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff. (9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3. ”

    Source location

    Peter SUDLOW · 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

    Lack of guidance linking Waterlow score determination to Tissue Viability Nurse referral

    Wider context from the report

    “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time. (2) There was no referral to the TVN when the sore was categorised as a grade 2. (3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17. (4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19. (5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made. (6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores. (7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit. (8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff. (9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3. ”

    Source location

    Peter SUDLOW · 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 of the Pressure Ulcer Prevention and Treatment booklet to reference Tissue Viability Nurse referral before Category or Grade 3 pressure ulcers

    Wider context from the report

    “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time. (2) There was no referral to the TVN when the sore was categorised as a grade 2. (3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17. (4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19. (5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made. (6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores. (7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit. (8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff. (9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3. ”

    Source location

    Peter SUDLOW · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester North

    AI-generated summary

    Christopher Byron · 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

    Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

    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 a documented and recorded referral process between District Nurses and Tissue Viability Nurses

    Wider context from the report

    “1. The Court heard evidence that since the death of Mr Byron the District Nursing and Tissue Viability Nurses (TVNs) are now managed as part of the Northern Care Alliance and are jointly located. However there is no documented policy for the referring of patients from the District Nurses to the TVNs. “Unofficial” referrals could occur by way of conversations within the office and there is no policy to ensure these are recorded in writing and recorded in the patients notes. The Court heard evidence that such a referral was thought to have occurred in September 2016 but this was not documented anywhere. 2. Likewise if a referral is sent by email there no instruction to staff that such email must be uploaded into the patients records in order for it to be clearly seen by all workers that the patient has been referred. ”

    Source location

    Christopher Byron · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Norfolk

    AI-generated summary

    Carol Anne JENNINGS · 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 Anne Jennings had multiple comorbidities and was admitted to hospital on 10 January 2019. She developed infected leg ulcers, deteriorated, began end-of-life care on 25 January, and died on 31 January 2019; the inquest recorded septicaemia, infected leg ulcers and hospital-acquired pneumonia as the medical causes of death. Concerns included the handling and follow-up of a Tissue Viability Nurse referral and inadequate wound record keeping.

    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 act on tissue viability referrals when referral information is incomplete

    Wider context from the report

    “1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward. A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented. ”

    Source location

    Carol Anne JENNINGS · 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 chase up tissue viability referrals

    Wider context from the report

    “1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward. A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented. ”

    Source location

    Carol Anne JENNINGS · 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

    Implement a mandatory electronic TVN referral form, replacing telephone and answering-machine referrals and requiring accurate patient information.

    Verbatim wording from the response

    “A new electronic referral system will be in place during the first week of next month. As compared with the previous system involving telephone referrals and the practice of answering machine use, which is being discarded, there is now a new e-form which must be used in all cases. The e-form must only be emailed to the TVN nurse as indicated and the referral form’s design means that correct and accurate information about the patient must be included so that the referral and response is efficiently conducted by the TVN. A copy of that form is attached for your information.”

    Source location

    2019-0279-Response-by-Queen-Elizabeth-Hospiatl-Kings-Lynn-NHS-Trust
    Page 1 · response
    Published 18 October 2019

    Open published response

  9. Surrey

    AI-generated summary

    June Evelyn Evans · 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

    June Evelyn Evans was admitted to St Peter’s Hospital with diarrhoea and was assessed as being at high risk of pressure sores. She developed a severe hospital-acquired pressure sore that became infected, and she died of sepsis on 1 July 2016. The principal concerns were failures to prevent and promptly refer and treat the pressure sore, inadequate nutrition, clinicians’ delayed awareness of the sore, and understaffing across the wards.

    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 refer hospital-acquired grade 3 pressure sores to the tissue viability nurse

    Wider context from the report

    “1. The evidence showed that failure to refer the hospital acquired grade 3 pressure sore to the tissue viability nurse on the 8th June 2016 was as a result of the employment of an agency nurse who was unfamiliar with the Trust’s Policy on the Prevention of Pressure Sores. If the referral had been made to the tissue viability nurse on the 8th June 2016 it would not have deteriorated as it did. ”

    Source location

    June Evelyn Evans · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Norman Arthur BEARD · 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

    Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.

    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

    Delays in referral to Tissue Viability Nurses

    Wider context from the report

    “(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided. ”

    Source location

    Norman Arthur BEARD · 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