First reported 20 Aug 2013•Latest report 12 Mar 2026
Definition
What this concern includes
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.
Not included
Excludes generic wound-care deficiencies where pressure ulcers are not materially identified.
Excludes generic staffing, training, documentation or communication failures unless they directly impair pressure-ulcer prevention or management.
Excludes management of wounds caused by other mechanisms, including impact injuries, unless the report explicitly connects them to pressure-ulcer care.
Excludes unrelated delays, discharge or treatment failures where pressure-ulcer management is not the shared unsafe condition.
Reports
51
Distinct published reports
Individual concerns
106
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
135
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Care Quality Commission7
Department of Health and Social Care4
NHS Greater Manchester Integrated Care Board3
East Sussex Healthcare NHS Trust2
University Hospitals Birmingham NHS Foundation Trust2
Aneurin Bevan University LHB1
Angel Solutions (UK) Ltd1
Barchester Healthcare Limited1
Bargoed Care Home1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Beech Dene Residential Care Home1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Brunswick Ward at Lindridge1
Bryntirion Surgery1
Care First Homes1
NHS trust27
Health and social care service regulator7
Healthcare site7
Residential care home6
Integrated care board5
Private limited company5
Domiciliary care provider4
Ministerial department4
Type not available4
Care-home operator2
Company limited by guarantee2
English county council2
English unitary authority2
Executive non-departmental public body2
Local health board2
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
East London
Concerns raised2
Lack of a system for mandatory pressure ulcer training
Failure to adequately assess sacral pressure ulcers
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised2
Failure to consider documented pressure-ulcer risk when issuing care instructions
Failure to arrange pressure-relieving bed and mattress replacement before discharge
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.28
Action
Update home-held care-plan templates with clear carer instructions, escalation criteria and community nurse contact details.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Share discharge communications and care plans with all providers involved in patients’ care.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Train registered nurses to add discharge-relevant nursing notes to Epic discharge summaries; training is complete for senior ward nurses.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Contribute to developing the NCL tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.
Stated by University College London Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Contact district nurses whenever they are involved in an adult’s care to incorporate pressure-ulcer and other relevant needs into care plans.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.
Stated by Kapital Care (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Contact adult social care to request care-plan updates when additional needs are identified during initial visits or risk assessments.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
Stated by Westminster City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Update standard operating procedures with social-worker training, a discharge checklist, and escalation links with community providers.
Stated by Westminster City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Contribute to development of the North Central London tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Communicate to staff the referral-screening process requiring completion of skin and nursing sections before referrals reach community partners.
Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
Stated by University College London Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Contact district nurses whenever they are involved in an adult’s care arrangements.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Request relevant assessments, care information and emergency contact details from involved professionals.
Stated by Kapital Care (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review hospital discharge information and discharge letters to identify care-delivery needs.
Stated by Kapital Care (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Contact adult social care to request care-plan updates when additional needs are identified.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Complete manual-handling, mobility-equipment and environmental assessments before or during the initial visit.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Use a discharge checklist to verify equipment, district nurse involvement and care-agency briefing before discharge.
Stated by Westminster City CouncilStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Complete manual-handling, mobility-equipment and environmental assessments during initial visits.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Stated by University College London Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Sefton St Helens & Knowsley
Concerns raised1
Failure to document, assess and manage pressure sores or tissue injuries
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these 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.
Nottinghamshire
Concerns raised1
Failure to provide sufficiently responsive review of pressure-damage prevention needs
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.
Inner North London
Concerns raised1
Failure to make immediate tissue viability referrals for category 3 pressure ulcers
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review the referral process for Tissue Viability Nursing referrals.
Stated by Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2021.
Action
Revise and formally ratify Tissue Viability Nursing referral guidance, following staff consultation, with regular compliance audits.
Stated by Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2021.
West Yorkshire Eastern
Concerns raised1
Delays in providing a Nimbus Mattress
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Assess patients’ skin within four hours of transfer and order appropriate pressure-relieving equipment, including specialist mattresses when already required.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Stoke-on-Trent and North Staffordshire
Concerns raised3
Failure of district nurses to involve Tissue Viability Nurses
Failure to keep the pressure mattress switched on
Failure to check pressure areas
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide additional wound-care documentation training and verify staff completion through training-register checks.
Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
Action
Audit nursing documentation and pressure-ulcer management, using a developed audit tool and reporting findings to senior management.
Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
District nurses are skilled in wound management and refer to tissue viability specialists when wounds deteriorate, consistent with Trust policy.
Stated by Midlands Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The residential home is responsible for ensuring the pressure mattress is used appropriately.
Stated by Midlands Partnership University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Residential home carers are expected to conduct regular skin checks and contact district nurses when concerns arise.
Stated by Midlands Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised2
Lack of national guidance on managing and reducing pressure-ulcer risks in Emergency Departments
Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing NICE guidance addresses pressure-ulcer risk assessment in emergency departments, so no further action is required at this time.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing NICE guidance, local NHS policies and the emergency department safety checklist provide relevant arrangements for preventing and managing pressure ulcers.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Shropshire, Telford and Wrekin
Concerns raised6
Failure to refer patients to the Tissue Viability Nurse at indicated pressure-ulcer risk or severity points
Lack of guidance on Tissue Viability Nurse referrals for patients with paraplegia or neurological deficit
Lack of clear guidance on when and in what circumstances to refer patients to the Tissue Viability Nurse
Lack of guidance linking Waterlow score determination to Tissue Viability Nurse referral
Lack of guidance on Tissue Viability Nurse involvement in pressure-sore prevention plans for patients with additional risks
Failure of the Pressure Ulcer Prevention and Treatment booklet to reference Tissue Viability Nurse referral before Category or Grade 3 pressure ulcers
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.
Manchester South
Concerns raised1
Failure of pressure-ulcer forms to capture deterioration and require detailed monitoring
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Adopt the NHS wound-management document within the Quality Management System.
Stated by Olea Care LtdStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Implement an electronic care-planning system that uploads information and photographs in real time.
Stated by Olea Care LtdStated plannedThe respondent said that this action was planned when they made their response on 31 December 2019.
Action
Implement electronic pressure-ulcer photography at identification and regular intervals to monitor deterioration.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Adopt the Stockport pressure-ulcer monitoring form for consistent, regular monitoring.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2019.
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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.
