Recurring concern

Inadequate management of pressure ulcers

First to latest report 20 Aug 2013 — 12 Mar 2026

Reports that mention this concern
51
Times this concern has been raised
106
Stated actions linked to this concern
135

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.

What is 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 and published responses 51 reports

See individual reports that have raised this concern, and the actions taken in response

  1. County Durham and Darlington

    AI-generated summary

    Name not published · 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

    The deceased, who had a history of falls and was assessed as being at risk of falling, was found on the floor after an unwitnessed night and sustained injuries that subsequently led to her death. Concerns included the absence of adequate risk assessments for falls and pressure sores, and the failure to identify that a new mattress was unsuitable for her.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of risk assessment for falls and pressure sore risk

    Wider context from the report

    “(1) It became apparent that a risk assessment was not completed in relation to the deceased's falls and the pressure sore risk. The deceased was found on the floor after an unwitnessed night by a carer at approximately 4.00 hours. She sustained injuries which subsequently led to her death. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.

    Verbatim wording from the response

    “Steps are being taken to further minimise the risk that resident's face in situations such as this. Lambton House is currently in the process of phasing in through “Home Loans” the provision of air flow mattresses, where there has been an assessed need to aid pressure relief care. All new air flow mattresses are compatible with bed based pressure sensors. The aim is to eliminate the need for floor based pressure sensors, which in themselves can also create a risk of falls/trips.”

    Source location

    2016-0423-Response-by-Lambton-House-Care-Home
    Page 1 · response
    Published 26 February 2017

    Open published response

  2. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Norman Arthur BEARD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in referral to Tissue Viability Nurses

    Wider context from the report

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

    Source location

    Norman Arthur BEARD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 follow Tissue Viability Nurses advice

    Wider context from the report

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

    Source location

    Norman Arthur BEARD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 an upgraded mattress

    Wider context from the report

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

    Source location

    Norman Arthur BEARD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. London Inner (South)

    AI-generated summary

    DAPHNE MCCORKLE · 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

    Daphne McCorkle was discharged from hospital with a Grade 2 pressure sore, which deteriorated while she was receiving community care. She died in hospital on 20 November 2014 from sepsis caused by the infected pressure sore. Concerns included the frequency and quality of District Nurse visits and assessments, inadequate care-plan reviews and documentation, delayed referral to a Tissue Viability Nurse, lack of advice about night-time turning, and a gap in night-time care provision.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of nighttime care provision for patients requiring regular turning

    Wider context from the report

    “(1) On the expert evidence, there will be cases where a patient should be turned every 2/3 hours, even at night, to ensure that the risk of pressure sores being caused or worsened is properly managed. (2) In some cases where this level of turning is required, family members will not be able to perform that task. (3) However I was informed during the inquest that Lewisham District Nurses (for whom I understand the NHS Lewisham Clinical Commissioning Group is responsible) will not visit patients at home at night. (4) I was also informed that agency carers (whose care I understand is commissioned by the London Borough of Lewisham, Adult Social Care Department) will not visit at night either. (5) This leaves a gap in provision for some patients and is a concern. ”

    Source location

    DAPHNE MCCORKLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate a Community Pressure Ulcer Panel to review causes and risk factors and ensure adequate care, interventions and protection arrangements.

    Verbatim wording from the response

    “As commissioners of the Lewisham community District Nursing services, provided by Lewisham and Greenwich NHS Trust, we are responsible for ensuring the quality and safety of patients discharged to their care. We will take steps to ensure that there is a marked improvement in the risk assessment of patients who are discharged from hospital with pressure ulcers into the care of community services. We have established a Community Pressure Ulcer Panel with the Lewisham and Greenwich NHS Trust and London Borough of Lewisham as part of adult safeguarding processes to review the causes and predisposing factors of pressure ulcers and to ensure that adequate care, interventions and protection arrangements are in place.”

    Source location

    D-McCorkle-Response
    Page 1 · response
    Published 19 September 2016

    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

    Support patients discharged to family care and arrange alternatives, including continuing healthcare assessment, when families cannot provide adequate support.

    Verbatim wording from the response

    “Additionally we established an “acute pressure ulcer panel” which reviews the Root Cause Analysis (RCAs) of all pressure ulcers acquired in the community and ensures the lessons learned are taken back to practice. This has seen a significant reduction in community acquired pressure ulcers and changed practice in skin care by Domiciliary Care Agencies. We will also take steps to ensure that where a patient is discharged by choice into the care of their family, they are supported to be able to care for them at home. When a family is unable to provide this level of support, the patient should not be discharged home and alternative arrangements made including assessment for eligibility for Continuing Health Care (CHC) in a nursing home. We will be monitoring this through our contract management process at the Clinical Quality Review Group (CGRQ).”

    Source location

    D-McCorkle-Response
    Page 1 · response
    Published 19 September 2016

    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

    Monitor discharge support and alternative arrangements through contract management at the Clinical Quality Review Group.

    Verbatim wording from the response

    “Additionally we established an “acute pressure ulcer panel” which reviews the Root Cause Analysis (RCAs) of all pressure ulcers acquired in the community and ensures the lessons learned are taken back to practice. This has seen a significant reduction in community acquired pressure ulcers and changed practice in skin care by Domiciliary Care Agencies. We will also take steps to ensure that where a patient is discharged by choice into the care of their family, they are supported to be able to care for them at home. When a family is unable to provide this level of support, the patient should not be discharged home and alternative arrangements made including assessment for eligibility for Continuing Health Care (CHC) in a nursing home. We will be monitoring this through our contract management process at the Clinical Quality Review Group (CGRQ).”

    Source location

    D-McCorkle-Response
    Page 1 · response
    Published 19 September 2016

    Open published response

  4. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to verify correct pressure mattress function

    Wider context from the report

    “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly. ”

    Source location

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate staff training in pressure mattress management

    Wider context from the report

    “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly. ”

    Source location

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record identified pressure mattress faults

    Wider context from the report

    “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly. ”

    Source location

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to carry out pressure sore repositioning plans

    Wider context from the report

    “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses. ”

    Source location

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Falsification of pressure sore repositioning records

    Wider context from the report

    “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses. ”

    Source location

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Share investigation learning with New Park House and recommend improvements to recording practices.

    Verbatim wording from the response

    “Some turns had been missed but Mrs Kaiser was known to regularly refuse to comply with the turn regime in place. It was acknowledged that such refusals were not always documented and the home took this away as a recommendation from the investigation for further work with the staff.”

    Source location

    2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
    Page 3 · response
    Published 14 July 2015

    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

    Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.

    Verbatim wording from the response

    “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.”

    Source location

    2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
    Page 4 · response
    Published 14 July 2015

    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 investigation found no evidence that the pressure-sore management plan was inadequately followed or that records had been falsified.

    Verbatim wording from the response

    “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.”

    Source location

    2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
    Page 3 · response
    Published 14 July 2015

    Open published response

  5. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mr. Arthur Cook · 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

    Mr. Arthur Cook had poor circulation and a chronic open wound that developed into an MRSA-infected category 4 pressure ulcer while he was resident at Four Seasons Healthcare Residential Home. He failed to respond to treatment and died. Concerns included insufficient tissue viability nursing capacity, inadequate pressure-ulcer documentation and repositioning charts, and a lack of integrated skin care across services.

    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 maintain adequate pressure ulcer documentation

    Wider context from the report

    “(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”

    Source location

    Mr. Arthur Cook · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Birmingham and Solihull

    AI-generated summary

    Doreen England · 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

    Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of staff knowledge about pressure sore formation and prevention

    Wider context from the report

    “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk. ”

    Source location

    Doreen England · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide staff training on pressure sore formation and prevention

    Wider context from the report

    “(2) Since these events staff confirmed at the inquest that they had still not had training on pressure sore formation and prevention. ”

    Source location

    Doreen England · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to prepare care plans for patients at high risk of pressure sore formation

    Wider context from the report

    “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk. ”

    Source location

    Doreen England · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate RMN training on pressure sores

    Wider context from the report

    “(4) Registered Mental Health Nurses at the inquest confirmed their RMN training had not covered the subject of pressure sores in any detail and they felt they had inadequate awareness and knowledge. This is a subject that should be covered in the RMN curriculum. ”

    Source location

    Doreen England · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Birmingham Cross City CCG commissions the service and is undertaking work to address the identified care deficiencies.

    Verbatim wording from the response

    “It is also a significant concern that at the time of the inquest the organisation involved does not appear to have responded in correcting these issues. We are in communication with Birmingham Cross City CCG which has undertaken a significant amount of work in relation to this case already and who commission the service and will also ensure CQC are aware of the case.”

    Source location

    2015-0291-Responses
    Page 7 · response
    Published 23 July 2015

    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

    Responsibility for setting nursing curricula and training standards rests with the Nursing and Midwifery Council, not Health Education England.

    Verbatim wording from the response

    “While HEE have a responsibility for promoting high quality education and training, they are not responsible for setting curricula or the standards of training; in this instance this would be the responsibility of the Nursing and Midwifery Council (NMC). Nevertheless, HEE have confirmed that they will work with the NMC to influence training and curricula as appropriate.”

    Source location

    2015-0291-Responses
    Page 4 · response
    Published 23 July 2015

    Open published response

  7. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    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

    Pressure damage to the hips and buttocks

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. West Sussex

    AI-generated summary

    James Bateley · 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

    James Bateley was admitted to Worthing Hospital with severe pressure sores and died on 6 June 2014; the stated cause of death included bronchopneumonia, sepsis, necrotising fasciitis and a pressure wound. The report raised concern that nursing homes and community nurses did not have ready access to necessary dressings, which could take up to 14 days to arrive and meant that, in Mr Bateley’s case, staff borrowed dressings from another resident.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of ready access to necessary dressings for nursing homes and Community Nurses treating pressure sores

    Wider context from the report

    “During the evidence it became apparent that neither the nursing home, where Mr Bateley was living, nor the Community Nurses, who had been called in to assist in treating Mr Bateley’s pressure sores had ready access to the necessary dressings. There was evidence given that these dressings are not readily available to nursing homes or the Community Nurses who regularly have to treat this type of ailment. The dressings have to be ordered through the GP and we were told that it could take up to 14 days for them to arrive. In Mr Bateley’s case staff had to borrow and make use other resident’s dressings. Sadly Mr Bateley was taken into hospital before his dressings arrived. Whilst the absence of these dressing was unlikely to have contributed directly to Mr Bateley’s death there is concern for others in the future who cannot rely on others to borrow dressing from. ”

    Source location

    James Bateley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a stock box and first-dressing system for patients beginning care.

    Verbatim wording from the response

    “A number of immediate actions have already been taken, namely:”

    Source location

    2015-0115-Response-by-Sussex-Community-NHS-Trust
    Page 1 · response
    Published 23 March 2015

    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 an escalation process for delays in dressing-supply responses.

    Verbatim wording from the response

    “A number of immediate actions have already been taken, namely:”

    Source location

    2015-0115-Response-by-Sussex-Community-NHS-Trust
    Page 1 · response
    Published 23 March 2015

    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

    Run the ONPOS ordering service in shadow mode for six to twelve months.

    Verbatim wording from the response

    “Longer-term actions to improve this area of service are being discussed with the CCG. Once engagement and agreements are in place an ONPOS (On-Line Non Prescription Ordering Service) will be run in shadow from July for a 6-12 month period with the plan to roll this out in full from January 2016.”

    Source location

    2015-0115-Response-by-Sussex-Community-NHS-Trust
    Page 1 · response
    Published 23 March 2015

    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

    Roll out the ONPOS ordering service fully after the shadow period.

    Verbatim wording from the response

    “Longer-term actions to improve this area of service are being discussed with the CCG. Once engagement and agreements are in place an ONPOS (On-Line Non Prescription Ordering Service) will be run in shadow from July for a 6-12 month period with the plan to roll this out in full from January 2016.”

    Source location

    2015-0115-Response-by-Sussex-Community-NHS-Trust
    Page 1 · response
    Published 23 March 2015

    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

    Investigate the delay in ordering dressings and the application and use of non-prescribed dressings through the Deputy Chief Nurse.

    Verbatim wording from the response

    “The matter was referred to our Quality Assurance team whereby a representative met with the Head of Medicines Management CWS CCG, Deputy Designated Nurse: Safeguarding Adults, CWS CCG, the Residential Care Home concerned and a representative of the GP Surgery to investigate dressings not being available and the process undertaken by the Community Nurses who regularly have to treat this type of ailment and the delay in the order of such dressings.”

    Source location

    2015-0115-Response-by-Coastal-West-Sussex-Clinical-Commissioning-Group
    Page 1 · response
    Published 23 March 2015

    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 pharmacy did not delay processing the dressings order.

    Verbatim wording from the response

    “Assurance has been obtained from the Pharmacy used by the Residential Care Home and we are satisfied there was no delay in processing the dressings order.”

    Source location

    2015-0115-Response-by-Coastal-West-Sussex-Clinical-Commissioning-Group
    Page 2 · response
    Published 23 March 2015

    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 prescription request delay was not detrimental because appropriate dressings were available from residential home stock.

    Verbatim wording from the response

    “We would like to reaffirm the patient did receive appropriate treatment by the Community Nurses and the delay in the prescription request was not detrimental to the patient’s physical health, as the appropriate dressings were used from within the Residential Home’s stock.”

    Source location

    2015-0115-Response-by-Coastal-West-Sussex-Clinical-Commissioning-Group
    Page 2 · response
    Published 23 March 2015

    Open published response

  9. Sunderland

    AI-generated summary

    Leonard Henry Hudson · 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

    Leonard Henry Hudson fell at home, was admitted for surgery to repair a fractured right femur, later underwent a below-knee amputation, and died from bronchopneumonia on 19 March 2014. Concerns included failures in pressure-ulcer reporting and management, delayed referral to the foot protection team, incomplete nursing documentation, variable classification of heel injuries, and other deficiencies or confusion in records, mobilisation, fluid restrictions, physiotherapy, hygiene arrangements and diabetes information.

    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 patients with relevant co-morbidities as higher risk

    Wider context from the report

    “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted. Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor. Mr Hudson ought to have been referred to the foot protection team in a more timely manner. The nursing documentation was not as comprehensive as it ought to have been. The classification of Mr Hudson’s heel injuries was “variable”. From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team. During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: - 1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this; 2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist; 3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis; 4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy; 5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met; 6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1. All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding. However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention. I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths. ”

    Source location

    Leonard Henry Hudson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Manchester South

    AI-generated summary

    Leslie Alfred Pates · 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

    Leslie Alfred Pates was admitted to hospital, discharged home against his family’s wishes, and later transferred to a nursing home before being readmitted to hospital in a deteriorated condition. The principal concerns were failures in communication and discharge planning, including the absence of a family meeting, insufficient consideration of the family’s views, and discharge with severe pressure sores without a pressure-relieving mattress.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a pressure-relieving mattress at discharge home

    Wider context from the report

    “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient. 3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. 4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge. ”

    Source location

    Leslie Alfred Pates · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Discharge home with severe pressure sores

    Wider context from the report

    “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient. 3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. 4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge. ”

    Source location

    Leslie Alfred Pates · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.

    Verbatim wording from the response

    “All patients returning home with care package will have their equipment needs assessed and documented in hospital.”

    Source location

    2014-0043-Response-by-Tamside-Hospital-NHS
    Page 2 · response
    Published 30 January 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026