Recurring concern

Unreliable referrals to tissue viability services

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First reported 7 Aug 2013•Latest report 11 Jun 2025

Definition

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

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.

Beech Dene Residential Care Home1

Care First Homes1

East Sussex Healthcare NHS Trust1

Leeds City Council1

Leeds Community Healthcare NHS Trust1

Leek Health Centre1

Meanwood Group Practice1

Midlands Partnership University NHS Foundation Trust1

Moorfield House Surgery1

National Institute for Health and Care Excellence1

New Park Residential Home1

NHS Greater Manchester Integrated Care Board1

Northern Care Alliance NHS Foundation Trust1

Pennine Care NHS Foundation Trust1

Recipient name withheld1

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.

14 Sep2015
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. 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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The investigation found that advice and support had been sought from Tissue Viability Nurses through three referrals and assessments in June and July 2014.
  Stated by Stoke-on-Trent City CouncilDisputes the concern
AI-generated summary

Janine Eugenie Pierrette KAISER · 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

Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.

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
“6. Referral to Tissue Viability nurses should have been done sooner. ”
Source location
Janine Eugenie Pierrette KAISER · 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
The investigation found that advice and support had been sought from Tissue Viability Nurses through three referrals and assessments in June and July 2014.

Verbatim wording from the response
“6. The referral to Tissue Viability Nurses should have been made sooner.”

Source location
2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Page 4 · response
Published 14 July 2015
Open published response
17 Nov2014
West Yorkshire (East)
Concerns raised2
1. Delays in District Nurse referrals to the Tissue Viability Nurse Service
2. Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service
This report raised 14 other concerns. 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs Gladys Smith · 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

Mrs Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.

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 District Nurse referrals to the Tissue Viability Nurse Service
Wider context from the report
“(b) Mrs Smith was referred to the Tissue Viability Nurse Service on or around 25 June 2012, some 12 days after a referral ought to have been made according to expert evidence adduced in the course of the Inquest. In the circumstances, the Trust should ensure District Nurses make referrals to the Tissue Viability Nurse Service timeously; ”
Source location
Mrs Gladys Smith · Prevention of Future Deaths report
Page 1 · 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
Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service
Wider context from the report
“(c) The Trusts Clinical Guidelines for Wound Management in Adults and Children omits to provide guidance as to when District Nurses should refer patients to the Tissue Viability Nurse Service. In the circumstances, the Trust should amend the said Clinical Guidelines in order to provide comprehensive guidance as to when such a referral to the said Service should be made ”
Source location
Mrs Gladys Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Aug2013
Manchester (West)
Concerns raised1
1. Failure to involve tissue viability specialists when needed
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jean Miller · 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

Jean Miller was admitted for incisional hernia repair, discharged home under district nursing care, and later readmitted with a purulent wound discharge before dying in hospital on 24 January 2013. The report identified concerns about the district nursing team’s lack of baseline wound assessments, failure to involve tissue viability specialists, absence of thermometers, poor record keeping, and poor communication with the GP.

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 involve tissue viability specialists when needed
Wider context from the report
“1. The quality of care offered by the district nursing team arising from poor practices being in place in particular a lack of baseline assessments and poor understanding of the need to involve tissue viability specialists in such cases as Mrs Miller’s ”
Source location
Jean Miller · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in referral to Tissue Viability Nurses

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Delays in District Nurse referrals to the Tissue Viability Nurse Service

Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service

Concerns raised1

Failure to involve tissue viability specialists when needed

Respondent positions 1