Recurring concern
Unreliable referrals to tissue viability services
Pin
Get email alerts
Request correctionFirst reported 7 Aug 2013•Latest report 11 Jun 2025
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.
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
- 13
- Individual concerns
- 19
- Date range
- 2013–2025
- Stated actions
- 10
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.
-
Concerns raised1
Delays in referral to tissue viability services
This report raised 11 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
-
Action
Conduct weekly and monthly management audits of pressure-care records, actions, professional input, care plans and risk assessments.
Stated by Red Oaks Care Home
-
Concerns raised1
Failure to make appropriate tissue viability referrals
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.5
-
Action
Review the Tissue Viability referral process to prevent inappropriate rejection of referrals.
Stated by Meanwood Group Practice -
Action
Update GP and practice nursing knowledge, training and wound-care processes in line with Leeds guidelines.
Stated by Meanwood Group Practice -
Action
Audit patients receiving regular practice wound care monthly, moving to three-monthly audits once the system is assured.
Stated by Meanwood Group Practice
-
Action
Adopt four-week escalation triggers for non-improving foot and leg wounds, including podiatry or Tissue Viability referral consideration.
Stated by Meanwood Group Practice -
Action
Hold regular multidisciplinary discussions for complex or non-healing wounds and record outcomes in patient records.
Stated by Meanwood Group Practice
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Long-term wound care will be referred to specialist services, with the ICB expected to commission the necessary service.
Stated by Meanwood Group Practice
-
Concerns raised1
Delays in referral to tissue viability specialists
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.
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
-
Action
Undertake a pressure-ulcer prevention and management quality-improvement project with Tissue Viability Team support.
Stated by East Sussex Healthcare NHS Trust
-
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
-
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
-
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
-
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
-
Concerns raised5
Failure to refer patients to the Tissue Viability Nurse at indicated pressure-ulcer risk or severity points
Lack of guidance on Tissue Viability Nurse referrals for patients with paraplegia or neurological deficit
Lack of clear guidance on when and in what circumstances to refer patients to the Tissue Viability Nurse
Lack of guidance linking Waterlow score determination to Tissue Viability Nurse referral
Failure of the Pressure Ulcer Prevention and Treatment booklet to reference Tissue Viability Nurse referral before Category or Grade 3 pressure ulcers
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of a documented and recorded referral process between District Nurses and Tissue Viability Nurses
This report raised 10 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.
-
Concerns raised2
Failure to act on tissue viability referrals when referral information is incomplete
Failure to chase up tissue viability referrals
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.1
-
Action
Implement a mandatory electronic TVN referral form, replacing telephone and answering-machine referrals and requiring accurate patient information.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
-
Concerns raised1
Failure to refer hospital-acquired grade 3 pressure sores to the tissue viability nurse
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Delays in referral to Tissue Viability Nurses
This report raised 15 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