Concerns raised 1
Delays in moving patients to prevent pressure sore deterioration View source
This report raised 6 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.
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AI-generated summary
Raymond Albert Alfred Reid · 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
Raymond Albert Alfred Reid was admitted to hospital with a catheter-related urinary tract infection, developed pressure sores and pneumonia during a prolonged stay, and died on 1 March 2023. The report identified concerns about gaps in pressure sore prevention, monitoring, documentation, nutritional screening, repositioning, wound follow-up and photography.
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× 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 moving patients to prevent pressure sore deterioration
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” Source location Raymond Albert Alfred Reid · Prevention of Future Deaths report
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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 reported tissue-damage incidents, take immediate local learning actions, and assess implications for the Trust-wide improvement plan.
Verbatim wording from the response “From this, you can see that there is a huge amount of work covered by the Group. All Care Groups attend the quarterly meeting and it is jointly led by the two Trust Tissue Viability Leads. All reported incidents of tissue damage are reviewed by the TV team in collaboration with the Care Group Senior Nurses. Immediate local learning/actions will be taken following this initial review. All incidents will also be reviewed to determine any implications for the Trust wide TV improvement plan. Trends and discrepancies in care can be identified centrally and early work can then be done to improve patient care.” Source location Response from Royal Devon Healthcare NHS
Open published response
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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 Establish a Northern-site leadership workstream to strengthen front-line nursing practice in pressure-ulcer prevention and management, with senior oversight of delivery.
Verbatim wording from the response “In order to ensure that this is actually being delivered on the front line, the Chief Nursing Officer has commissioned a significant leadership piece of work from the Director of Nursing on the Northern site. She has been asked to ensure we have right systems and processes for care in Northern services and specifically looking to “foster leadership in best practice in front line nursing staff who have ward based responsibilities regarding the day to day prevention and management of pressure ulcers”. This Group is being set up and delivery against the agreed actions will be report to the Tissue Viability Group and the Patient Safety Committee so again there will be high level and senior oversight of this piece of work.” Source location Response from Royal Devon Healthcare NHS
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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 Existing Trust-wide pressure damage prevention arrangements provide sufficient assurance that further work and dissemination are not required.
Verbatim wording from the response “I am pleased to be able to write and provide you with real assurance that the Trust is doing significant work to reduce pressure damage in patients and I hope you will be reassured that this has been a priority of the Trust for some time now and substantial work is being done to ensure improvements.” Source location Response from Royal Devon Healthcare NHS
Open published response
1 Nov 2024 Phyllis TROMANS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3
Lack of pressure area care for patients positioned on trolleys in the Emergency Department View source Underestimation of pressure sore risk View source Failure to adhere to scheduled repositioning intervals View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Phyllis TROMANS · 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
Phyllis Tromans, a long-term resident with Parkinson’s disease who was in a frail condition, developed a grade 4 pressure ulcer while an inpatient at Queen Elizabeth Hospital and died at Cotteridge House on 24 May 2024. Concerns included an underestimated pressure sore risk assessment, prolonged periods without repositioning, an incomplete wound care plan, and an investigation that did not establish why gaps in care had occurred.
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× 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 pressure area care for patients positioned on trolleys in the Emergency Department
Wider context from the report “1. It is likely that Mrs Tromans' tissue damage started during her period in the Emergency Department. On admission, her Waterlow score indicated a high risk of pressure sores. That score was underestimated and the correct score would have indicated a very high risk. She spent almost 18 hours in ED, during which time she was positioned on a trolley without pressure area care.
” Source location Phyllis TROMANS · Prevention of Future Deaths report
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 Underestimation of pressure sore risk
Wider context from the report “1. It is likely that Mrs Tromans' tissue damage started during her period in the Emergency Department. On admission, her Waterlow score indicated a high risk of pressure sores. That score was underestimated and the correct score would have indicated a very high risk. She spent almost 18 hours in ED, during which time she was positioned on a trolley without pressure area care.
” Source location Phyllis TROMANS · Prevention of Future Deaths report
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 adhere to scheduled repositioning intervals
Wider context from the report “2. Mrs Tromans had a repositioning schedule in place when she was admitted to the Acute Medical Unit and subsequently to ward East Ground B. This required repositioning at no greater intervals of four hours to mitigate the risk of pressure sores. On a total of 22 occasions the schedule was not adhered to. This led to occasions where Mrs Tromans was left in the same position for up to 14 hours.
” Source location Phyllis TROMANS · Prevention of Future Deaths report
Open source report
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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 Deliver targeted Emergency Department training on pressure-ulcer assessment, reporting, skin inspection and repositioning.
Verbatim wording from the response “In response to this, several measures are being taken to prevent future occurrences. Due to the increasing demand on the ED, which has led to patients spending longer than desirable periods in the department, the Tissue Viability team has collaborated with ED Matrons to implement a project aimed at reducing pressure ulcers in the ED. This includes:” Source location Response from University Hospitals Birmingham
Open published response
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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 Introduce pressure-relieving trolley mattresses and heel-offloading pillows for Emergency Department patients.
Verbatim wording from the response “In response to this, several measures are being taken to prevent future occurrences. Due to the increasing demand on the ED, which has led to patients spending longer than desirable periods in the department, the Tissue Viability team has collaborated with ED Matrons to implement a project aimed at reducing pressure ulcers in the ED. This includes:” Source location Response from University Hospitals Birmingham
Open published response
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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 Emergency Department trolley mattresses and establish a trolley-audit programme.
Verbatim wording from the response “Furthermore, skin champions have been introduced in the ED, with staff undergoing comprehensive training. The department is also working on auditing trolley mattresses to ensure they provide effective pressure reduction, with plans for a trolley audit program in place.” Source location Response from University Hospitals Birmingham
Open published response
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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 and relaunch the Waterlow-score documentation booklet across the Trust.
Verbatim wording from the response “• Documentation: A booklet supporting accurate completion of Waterlow scores is being updated and will soon be relaunched to ensure proper documentation across the Trust.” Source location Response from University Hospitals Birmingham
Open published response
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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 Deliver repositioning training for Tissue Viability Link Workers with therapy-team pressure mapping and safe side-lying education.
Verbatim wording from the response “• Training: In December, two Tissue Viability Link Worker events focused on repositioning were held, with support from therapy teams using pressure mapping devices to identify pressure points and promote effective repositioning. The sessions also provided education on anatomy and physiology, with an emphasis on safe side-lying techniques to relieve pressure.” Source location Response from University Hospitals Birmingham
Open published response
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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 Acute Medical Unit repositioning audits, provide real-time feedback and reinforce schedule compliance through staff communications.
Verbatim wording from the response “• Compliance Monitoring: A weekly audit of repositioning practices in the AMU is now being conducted, with real-time feedback provided to staff. The AMU also receives regular communications emphasizing the importance of following the repositioning schedule and completing daily care plans.” Source location Response from University Hospitals Birmingham
Open published response
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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 the Response Assessment Tool for senior-staff oversight of repositioning strategies and audit its compliance and quality.
Verbatim wording from the response “• Response Assessment Tool (RAT): The Tissue Viability team has implemented the RAT to scope trust-acquired pressure ulcer events. This tool, which will be used by senior staff to ensure repositioning strategies are being followed, will be audited for compliance and quality.” Source location Response from University Hospitals Birmingham
Open published response
30 Aug 2024 Wendy Ann AFFORD · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Failure to identify and assess high risk of pressure damage in skin-integrity risk assessments View source
This report raised 7 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.
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AI-generated summary
Wendy Ann AFFORD · 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
Wendy Ann Afford was bedbound and living alone with a package of care before developing worsening pressure damage and an infected pressure ulcer. After hospital treatment and discharge to a care home, her health declined and she died on 15 November 2023. Concerns included inadequate skin-integrity risk assessment and monitoring, incomplete repositioning records, unclear compliance with care plans, insufficient management oversight, and possible inadequate staff training.
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× 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 identify and assess high risk of pressure damage in skin-integrity risk assessments
Wider context from the report “1. The risk assessment for Mrs Afford in respect of her skin integrity did not record her high risk of developing pressure damage and it was entirely unclear how the risk was assessed in the first place .
” Source location Wendy Ann AFFORD · Prevention of Future Deaths report
Open source report
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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 Create an incident matrix covering skin-integrity documentation in risk assessments, care notes and care plans.
Verbatim wording from the response “Further to the incident that happened regarding the death of the late Wendy Afford, the following action plans have been taken and implemented:” Source location Response from Happy at Home Community Care Services Ltd
Open published response
14 May 2024 Carol Ann DIVALL · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 2
Delays in referral to tissue viability specialists View source Failure to maintain pressure-relieving mattress function View source
This report raised 7 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.
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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.
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× 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
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 maintain pressure-relieving mattress function
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
Open source report
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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
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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 completed Trust-wide inpatient-bed audit to determine effective next steps for mattress protection.
Verbatim wording from the response “We note the failure of the hybrid mattress pump in this case. Even in the event of failure, we would anticipate that the mattress provides sufficient protection to patients at risk of pressure damage, however we note this did not happen in this case. We recently completed a Trust-wide audit of all inpatient beds to understand the current picture and are considering the findings in order to ensure effective next steps.” Source location Response from East Sussex Healthcare
Open published response
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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 Complete daily hybrid-mattress-pump checks in pilot wards and address identified equipment issues.
Verbatim wording from the response “Additionally, as part of the QI project noted above, Benson Ward and Egerton Trauma Unit now complete daily checks on all hybrid mattress pumps and this is documented on a checklist (Attachment C). Actions are taken to supply pumps to those patients that need them (as all mattresses are hybrid) and address any issues with teams on the ward, who are” Source location Response from East Sussex Healthcare
Open published response
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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 Share learning from the hybrid-mattress-pump pilot areas across the Trust.
Verbatim wording from the response “supported by ‘trouble-shooting’ sheets (see attachment D). It is our intention to take learnings from these pilot areas and share across the Trust.” Source location Response from East Sussex Healthcare
Open published response
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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 A failed hybrid mattress pump would ordinarily still provide sufficient protection against pressure damage, although it did not do so in this case.
Verbatim wording from the response “We note the failure of the hybrid mattress pump in this case. Even in the event of failure, we would anticipate that the mattress provides sufficient protection to patients at risk of pressure damage, however we note this did not happen in this case. We recently completed a Trust-wide audit of all inpatient beds to understand the current picture and are considering the findings in order to ensure effective next steps.” Source location Response from East Sussex Healthcare
Open published response
Concerns raised 1
Uncompleted pressure-wound safety protocols View source
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 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.
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AI-generated summary
Stanley Cummins · 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
Stanley Cummins, aged 84, died at home on 2 September 2022 after a heel pressure ulcer became necrotic and led to sepsis. The inquest identified concerns about failures to provide appropriate pressure relief and offloading advice, make referrals, and implement comprehensive changes to his care, with further training and protocols still described as work in progress.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Uncompleted pressure-wound safety protocols
Wider context from the report “During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds.
I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals.
The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds , were described to me as being a work in progress with no certainty as to when these would be completed .
” Source location Stanley Cummins · Prevention of Future Deaths report
Open source report
2 Feb 2024 Susan Wendy Bracegirdle · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5
Failure to share pressure-ulcer care plans with the care team View source Lack of a communication strategy supporting joint working and family involvement in pressure-ulcer care View source Failure to upload updated images for Tissue Viability review of deteriorating pressure ulcers View source
Failure to provide the GP with sufficient information about pressure-ulcer deterioration View source Failure to share and discuss internal pressure-ulcer reviews with the family View source See 2 more concerns
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.
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AI-generated summary
Susan Wendy Bracegirdle · 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
Susan Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to share pressure-ulcer care plans with the care team
Wider context from the report “1. The inquest heard evidence that because Mrs Bracegirdle was in a care home setting the District Nurses were responsible for management of her pressure ulcers. The care home was asked to ensure pressure relieving processes were followed. However, the District Nurses did not share care plans with the care team on the basis that they were digital documents and were care plans for the use of District Nurses. As a consequence, the care home management were not fully sighted, and joint care was more difficult to deliver increasing the risk of the pressure ulcers deteriorating.
” Source location Susan Wendy Bracegirdle · Prevention of Future Deaths report
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 a communication strategy supporting joint working and family involvement in pressure-ulcer care
Wider context from the report “2. There was no communication strategy in place as a consequence of an approach that did not promote team /joint working . The inquest heard that as a consequence the family were unsighted on the condition of Mrs Bracegirdle until shortly before her admission to hospital . This meant that the family could not support the work to reduce the risk of the pressure ulcers deteriorating further and were not able to be a proactive about the care she was receiving increasing the risk of her pressure ulcers deteriorating
” Source location Susan Wendy Bracegirdle · Prevention of Future Deaths report
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 upload updated images for Tissue Viability review of deteriorating pressure ulcers
Wider context from the report “6. The Tissue Viability team had been asked by the District Nurses for input. This was provided remotely via access to photos taken by the District Nursing Team. Whilst it was clear that remote review could be effective it was not in this case because the review was based on an older image and an updated image showing a deteriorating picture in relation to the pressure ulcers was not uploaded . This was as a result of lack of joint working and effective communication. The impact was that what would have been helpful expert input from the TVN was not provided to a deteriorating picture.
” Source location Susan Wendy Bracegirdle · Prevention of Future Deaths report
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 provide the GP with sufficient information about pressure-ulcer deterioration
Wider context from the report “3. The GP was asked to provide input. Due to a lack of information sharing the GP who dealt with Mrs Bracegirdle does not seem to have appreciated the extent of the issue and as a consequence there was no face-to-face examination and antibiotics were not started.
” Source location Susan Wendy Bracegirdle · Prevention of Future Deaths report
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 share and discuss internal pressure-ulcer reviews with the family
Wider context from the report “5. An earlier internal review by the District Nursing team when Mrs Bracegirdle’s pressure ulcer became a category 3 was not shared or discussed with the family and they were unsighted on the issue .
” Source location Susan Wendy Bracegirdle · Prevention of Future Deaths report
Open source report
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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 an information leaflet explaining how families can contact District Nursing for pressure-area-care advice.
Verbatim wording from the response “In undertaking this review there was evidence of verbal communication with the care home staff and written notes within the communication book at the care home. However, an information leaflet will be developed to promote communication.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Include joint-working Quality Statements in the service’s next assessment and follow up actions addressing previously identified communication shortfalls.
Verbatim wording from the response “At our last inspection of Stable Steps Care Centre on 8 and 19 June 2023 we found that improvements were needed to ensure communication worked effectively within the home. Feedback from people living at the home and their families was mixed with some people feeling staff were responsive to their needs, whilst others gave examples of where they felt there had been delays in receiving treatment. Families also told us communication between healthcare services and the home could be difficult, staff were not always able to identify deterioration in people and that liaison and referrals with external services could be improved.” Source location Response from Care Quality Commission
Open published response
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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 Follow up the registered manager’s investigation into failures to keep families informed and seek assurance that resulting actions mitigate communication risks.
Verbatim wording from the response “We would expect, as parties to general reviews of care whilst at the home, a person’s family to be involved and informed, with the consent of the individual, regarding their care, treatment and progress. We note that the registered manager in her statement, advised that she had apologised to the family for the failure to keep them informed regarding Mrs Bracegirdle’s pressure ulcers and that she had committed to investigating this shortfall. We will follow up on the outcome of the investigation to seek assurance that any actions arising from the investigation will mitigate further risks that families are not kept informed where appropriate within acceptable timeframes.” Source location Response from Care Quality Commission
Open published response
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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 Photograph and upload every wound to the patient’s electronic record weekly.
Verbatim wording from the response “All wounds are to be photographed and uploaded on to the patient’s electronic record system once per week by the District Nursing Team.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Discuss with the nursing team the importance of following up concerns and actions directly with GPs rather than relying on care-home staff.
Verbatim wording from the response “During the Trust review of the pressure ulcer review, an area of learning was identified in relation to communication with the GP and an action was taken: This was to discuss with the nursing team the importance of following up any concerns or actions with the GP and not to rely on carers to ensure this is done. Since this rapid review, there have been no further incidents in relation to contact with GP practices.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Follow up actions establishing clear responsibility for escalating wound-care concerns to GPs.
Verbatim wording from the response “The district nursing notes dated 09 December 2022 refer to the wound having a strong malodour and heavy grey-yellow exudate. It was recorded “follow up with the GP as I suspect the wound is infected”. However, it is not clear whether the district nurses or care home staff had the responsibility for doing this. The second rapid review undertaken by the district nurse team leader on 16 December 2022 identified that there was no evidence that the concerns were escalated to the GP and a referral to the GP was only made on 13 December 2022, at which time antibiotics were commenced for a wound infection. Action arising from the rapid review was to discuss with the district nursing team the importance of following up any concerns or actions with the GP and not relying on the care staff to ensure this is done.” Source location Response from Care Quality Commission
Open published response
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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 Ensure a Being Open discussion occurs with patients or families after all rapid reviews deemed to involve no lapses in care, with compliance monitored monthly.
Verbatim wording from the response “However, the Trust acknowledge that a ‘Being Open’ conversation should have taken place with Mrs Bracegirdle’s next of kin to discuss the pressure ulcer damage and the outcome of the rapid review of the incident. Going forward the Trust will ensure that a ‘Being Open’ discussion does take place with patients or families for all raid reviews (which are deemed no lapses in care), and this will be monitored through the monthly Quality Assurance Meetings.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 care home provider is responsible for keeping family members updated about residents’ health, including pressure ulcer management and nursing advice.
Verbatim wording from the response “The care home provider would be expected to keep family members updated in relation to all aspects of a resident’s health and wellbeing as a matter of course, using the information from the communications book, and from direct conversations with the attending district nurses. In the event of further questions from the family then it would be expected for the care home staff to liaise with the attending team to obtain information to address those questions. This would include information about pressure ulcer management and any advice from community colleagues (District Nursing Team) or the TVN Team.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 It is unclear whether updated tissue-viability advice would have altered treatment, although providing an updated image would have been helpful.
Verbatim wording from the response “an updated image showing a deteriorating picture in relation to the pressure ulcers was not uploaded. This was as a result of lack of joint working and effective communication. The impact was that what would have been helpful expert input from the TVN was not provided to a deteriorating picture.” Source location Response from Care Quality Commission
Open published response
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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 registered GP had access to current District Nursing information through the shared electronic record, contrary to the concern that information was unavailable.
Verbatim wording from the response “Members of the District Nursing Team input their clinical notes onto the Emis clinical system; these notes are visible to a patient’s GP as they use the same clinical system. This does ensure that the registered GP does have access to full details of all District Nurse visits and treatments. This would include confirmation of referral to Tissue Viability Service and access to any wound photographs which may have been taken as these are uploaded into Emis.” Source location Response from Greater Manchester Integrated Care
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 GP could reasonably expect tissue viability specialists to lead pressure-ulcer treatment and advise the GP if treatment became ineffective.
Verbatim wording from the response “3. The GP was asked to provide input. Due to a lack of information sharing the GP who dealt with Mrs Bracegirdle does not seem to have appreciated the extent of the issue and as a consequence there was no face-to-face examination and antibiotics were not started.” Source location Response from Care Quality Commission
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 review panel found no District Nursing care lapses that directly contributed to the acquired pressure ulcers.
Verbatim wording from the response “The Division of Integrated Care at Stockport NHS Foundation Trust, carried out two rapid reviews in relation to Mrs Bracegirdle’s pressure ulcers, one in October 2022 and one in December 2022. These were presented to the Serious Incident Review Group (SIRG), chaired by the Deputy Director of Governance and panel members. The panel agreed that there were no lapses in care by the District Nursing Team which directly contributed to the” Source location Response from Greater Manchester Integrated Care
Open published response
1 Nov 2023 Sasha Honey MISHABI · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to provide adequate monitoring and oversight of pressure ulcer policy implementation View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sasha Honey MISHABI · 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
Sasha Honey MISHABI died at Queen Elizabeth Hospital Birmingham on 18 April 2023 after a cardiac arrest followed by overwhelming bronchopneumonia. He had severe physical and mental health conditions and skin ulcers that were later determined not to have significantly contributed to his death. The inquest identified failures at St Andrew’s Healthcare to complete required pressure-ulcer risk assessments and skin inspections, record them adequately, report lesions, and provide appropriate oversight, as well as failures in governance and serious-incident 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 Failure to provide adequate monitoring and oversight of pressure ulcer policy implementation
Wider context from the report “1. Awareness of and compliance with St. Andrew's Healthcare 'Pressure Ulcer Prevention and Management'
Policy
Due to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure damage and ought to have had weekly waterlow assessments and daily skin inspections with more frequent assessment and inspection to be considered in the event of change such as the development of an ulcer. Statements were provided from ████████, Consultant Psychiatrist, and ████████, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The statements included information on Mr. Mishabi's waterlow assessment and skin inspections, and provided some records. At no time was it identified that the SAH 'Pressure Ulcer Prevention and Management Policy' was not followed in Mr. Mishabi's case. At inquest it was identified that ████████ had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it). The areas of non compliance identified at inquest were as follows:
a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and 4.3 of the policy;
b. failure to carry out and/or adequately record daily skin inspections in accordance with paragraph 4.4 of the policy;
c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph 4.3 of the policy;
d. failure to consider increasing the frequency of skin inspections and carry out and/or adequately record any skin inspections between the identification of ulcers on the 15th March 2023 and the admission to hospital on the 17th March 2023 in accordance with paragraph 4.4 of the policy; and
e. failure to make a datix incident report when grade II lesions were identified on the 15th March 2023 in accordance with paragraph 4.7 of the policy; and
f. failure to provide adequate monitoring and oversight of the implementation of the policy in Mr. Mishabi's case in accordance with paragraph 5 of the policy . .
” Source location Sasha Honey MISHABI · Prevention of Future Deaths report
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 Establish substantive clinical, nursing and operations leadership with Quality Matrons and accountable physical-health governance oversight.
Verbatim wording from the response “Change 3: Clearer Accountability and Responsibility for Physical Healthcare
Since Mr Mishabi’s death, a triumvirate leadership team consisting of substantive postholders in the roles of Clinical Director, an Associate Director of Nursing and a Director of Operations is now in place.” Source location Response from St Andrew's Healthcare
Open published response
24 Jul 2023 Alan Christopher NIPPARD · Prevention of Future Deaths report Avon
View report summary
Concerns raised 10
Failure to identify pressure sore risk through screening View source Delays in completing initial pressure sore risk assessments View source Failure of nursing staff to detect and manage new pressure sores through daily checks View source
Delays in providing pressure-relieving mattresses View source Failure to provide structured repositioning and offloading of pressure areas View source Failure to complete weekly reassessment of high pressure sore risk View source Failure to provide heel-protective repose boots View source Failure to complete the SSKIN pressure sore prevention bundle adequately View source Failure to provide seated pressure relief View source Inadequate recording and categorisation of pressure damage on body maps View source See 7 more concerns
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 concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan Christopher NIPPARD · 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
Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.
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 identify pressure sore risk through screening
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong ; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing , in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 Delays in completing initial pressure sore risk assessments
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been .
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission , (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 nursing staff to detect and manage new pressure sores through daily checks
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks . In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 Delays in providing pressure-relieving mattresses
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress .
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 provide structured repositioning and offloading of pressure areas
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all . He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all .
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 complete weekly reassessment of high pressure sore risk
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved .
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 provide heel-protective repose boots
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all .
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 complete the SSKIN pressure sore prevention bundle adequately
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed .
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 provide seated pressure relief
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly .
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 Inadequate recording and categorisation of pressure damage on body maps
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · Prevention of Future Deaths report
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 Deliver face-to-face pressure-ulcer prevention and management training to substantive nursing, physiotherapy and occupational therapy staff.
Verbatim wording from the response “Since the inquest into Mr Nippard’s death, the Tissue Viability Nursing (TVN) Team have led a programme of face to face training for all substantive members of nursing staff on Pierce Ward. In addition, all Physiotherapists and Occupational Therapists have also received training.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
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 Complete and monitor staff workbooks assessing knowledge and skills in pressure-ulcer prevention and management.
Verbatim wording from the response “The training has focussed on addressing the learning from incidents which includes; consistently undertaking appropriate skin assessments, repositioning and the correct use of equipment. The training also incorporated training on the nationally recognised SKIN bundle which stands for ‘skin, surface, keep moving, incontinence, nutrition and hydration’ in addition to risk assessments, care planning, reporting and escalation. Staff knowledge and skills has been assessed using a workbook which has been distributed to and completed by each staff member. At the time of responding, 5 have not yet completed their work book which is being monitored and full compliance is expected.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
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 Pilot a bespoke tissue-viability monitoring tool capturing patient experience, outcomes and documentation compliance.
Verbatim wording from the response “A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and actions are in place to achieve 95%.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
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 Implement actions to improve documentation-audit compliance to 95%.
Verbatim wording from the response “A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and actions are in place to achieve 95%.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
Open published response
19 Jul 2023 Thelma Mary Radmore · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in initiating pressure ulcer prevention measures View source
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 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
Thelma Mary Radmore · 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
Thelma Mary Radmore was taken to hospital after a prolonged wait for an ambulance and then waited over 26 hours in the Emergency Department before transfer to a ward. She developed an unstageable sacral pressure ulcer and contracted Influenza A and Covid-19 in hospital, deteriorating rapidly before her death. The report identified concerns about delays caused by demand for ambulance, Emergency Department and bed capacity, and the effect of those delays on pressure-ulcer prevention.
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 initiating pressure ulcer prevention measures
Wider context from the report “1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available. The inquest heard evidence that the ambulance service challenges were exacerbated by waits outside Emergency Departments for space to become available for patients;
2. The wait Mrs Radmore experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards;
3. In Mrs Radmore’s case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage ;
4. The inquest was told the situation had been ongoing throughout the preceding days and such delays were not unusual across the North West and nationally.
” Source location Thelma Mary Radmore · Prevention of Future Deaths report
Open source report
28 Jun 2023 George Edward GRIFFITHS · Prevention of Future Deaths report Herefordshire
View report summary
Concerns raised 2
Delays in reassessment and implementation of pressure relieving measures View source Lack of preventative pressure area care View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Edward GRIFFITHS · 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
George Edward GRIFFITHS was admitted to hospital with acute kidney injury, gastritis, poorly controlled diabetes and infected toes, and later developed sepsis, COVID, delirium and a significant pressure sore during his prolonged admission. The report states that doctors believed the hospital-acquired pressure sore contributed to his death. Concerns included prolonged time in the emergency department without footwear removal, inadequate pressure-area prevention and delayed reassessment and pressure-relieving measures.
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 reassessment and implementation of pressure relieving measures
Wider context from the report “(2) Skin inspection on admission confirmed that all areas were intact but there is no evidence of preventative care despite patients’ time on ED (40 hours) and in AMU (5 days). Acknowledgement of pressure area damage occurred on the 8th February but no reassessment took place until the 20th February with consequent failure to implement pressure relieving measures .
” Source location George Edward GRIFFITHS · Prevention of Future Deaths report
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 preventative pressure area care
Wider context from the report “(2) Skin inspection on admission confirmed that all areas were intact but there is no evidence of preventative care despite patients’ time on ED (40 hours) and in AMU (5 days). Acknowledgement of pressure area damage occurred on the 8th February but no reassessment took place until the 20th February with consequent failure to implement pressure relieving measures.
” Source location George Edward GRIFFITHS · Prevention of Future Deaths report
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 Introduce senior nurse care reviews for patients spending extended periods in the Emergency Department.
Verbatim wording from the response “The ED has since recognised the need to implement new ways of working in response to the sustained pressures and patients spending far longer in the department than we would like. In response, we introduced a senior nurse care review, to meet the needs of those patients spending a long time in ED waiting for a bed. The care review is akin to the review ward based nurses would undertake and is intended to ensure that comprehensive care assessments and planning that would not ordinarily happen in an Emergency Department are undertaken.” Source location Response from Wye Valley NHS Trust
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 the Trust pressure-area-care policy to cover Emergency Department care.
Verbatim wording from the response “A thematic review of pressure damage cases in ED has also identified further areas for improvement that will be formalised into a departmental improvement plan. This includes a review of our Trust policy, which currently focusses on pressure area care in inpatient areas. The policy is being updated and an” Source location Response from Wye Valley NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add an Emergency Department standard operating procedure for timely, systematic pressure-area care.
Verbatim wording from the response “A thematic review of pressure damage cases in ED has also identified further areas for improvement that will be formalised into a departmental improvement plan. This includes a review of our Trust policy, which currently focusses on pressure area care in inpatient areas. The policy is being updated and an” Source location Response from Wye Valley NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an automated dashboard showing assessment and care-plan status to nurses in charge.
Verbatim wording from the response “Having moved from a paper assessment and care planning system onto a digital platform we have recognised that senior nursing oversight (nurse in charge) of the status of all patient assessments is not as accessible and obvious as when documentation was kept at the end of the patients’ bed. Part of our improvement plan is to develop an automated dashboard on the digital system, which will enable the nurse in charge to check the status of assessments and care plans for all patients in their charge. In addition, the assessment document itself is being reviewed to simplify the steps for completion and to add in prompts for accessing equipment/referring for specialist advice etc.” Source location Response from Wye Valley NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and simplify the assessment document, adding prompts for equipment and specialist referrals.
Verbatim wording from the response “Having moved from a paper assessment and care planning system onto a digital platform we have recognised that senior nursing oversight (nurse in charge) of the status of all patient assessments is not as accessible and obvious as when documentation was kept at the end of the patients’ bed. Part of our improvement plan is to develop an automated dashboard on the digital system, which will enable the nurse in charge to check the status of assessments and care plans for all patients in their charge. In addition, the assessment document itself is being reviewed to simplify the steps for completion and to add in prompts for accessing equipment/referring for specialist advice etc.” Source location Response from Wye Valley NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Modify the equipment-library request process so pressure-relieving mattresses and chair cushions are routinely supplied together.
Verbatim wording from the response “Early identification of the need for pressure relieving equipment is crucial to support better pressure area care. The Trust has modified the request process from the equipment library so that pressure relieving mattresses and chair cushions are provided routinely as part of the same request.” Source location Response from Wye Valley NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide new pressure-relieving mattress toppers on all Emergency Department trolleys.
Verbatim wording from the response “The ED department has recently invested in new mattress toppers for all ED trolleys to mitigate the risk of patients developing pressure damage in the event a patient has a longer than expected wait in the department and for those patients most at risk a bed and air mattress can be requested.” Source location Response from Wye Valley NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and pilot a local pressure-area-care competency package in high-risk clinical areas.
Verbatim wording from the response “In addition to core training, e-learning modules are available for all staff to refresh their skills and knowledge. A local competency package has been developed and has been piloted in areas where patients are most at risk (Frailty service). Once this has been evaluated, the competency programme will be rolled out more widely in the Medical Division, which will include the Emergency Department and Acute Medical Unit.” Source location Response from Wye Valley NHS Trust
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PFD Monitor interpretation Roll out the competency programme across the Medical Division, including Emergency Department and Acute Medical Unit areas, after evaluation.
Verbatim wording from the response “In addition to core training, e-learning modules are available for all staff to refresh their skills and knowledge. A local competency package has been developed and has been piloted in areas where patients are most at risk (Frailty service). Once this has been evaluated, the competency programme will be rolled out more widely in the Medical Division, which will include the Emergency Department and Acute Medical Unit.” Source location Response from Wye Valley NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh Tissue Viability link-nurse roles and provide additional training to their role holders.
Verbatim wording from the response “The Trust has Tissue Viability link nurse roles across the wards and relevant departments. This role has been refreshed as part of our overarching improvement plan and the individuals have received additional training. These members of staff are ‘on the ground’ experts and can provide timely advice and make recommendations for treatment plans. In addition, the Tissue Viability team are there to provide specialist advice if the ward based team feel specialist input is required and referral is necessary.” Source location Response from Wye Valley NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly multidisciplinary Pressure Ulcer panels and use rapid reviews to identify omissions, rectify care and capture learning.
Verbatim wording from the response “The Trust also holds a weekly Pressure Ulcer panel with subject matter experts (Tissue Viability/ Safeguarding/ Quality & Safety/ Therapies/ Matrons) where all incidences of pressure damage are discussed. Ward managers are invited to complete rapid reviews so that any omissions of care can be identified and rectified and to ensure learning takes place.” Source location Response from Wye Valley NHS Trust
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Includes failures of controls specifically dedicated to pressure-ulcer prevention and management, including risk assessment, prevention measures, clinical assessment, treatment, monitoring, specialist referral, equipment, repositioning and escalation across community and inpatient care.
