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. Inner South London

    AI-generated summary

    Mohammed Mozammel Hussain CHAUDHURY · 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

    Mohammed Chaudhury suffered multiple injuries in a traffic collision and later developed five severe, septic pressure sores while in hospital. The report raised concerns about inadequate turning, incomplete care planning and tissue-viability referrals, inconsistent risk scoring, shortages in nursing staff, and uncertainty about whether staffing levels for unconscious patients requiring regular turning were safe.

    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 follow pressure sore prevention guidance

    Wider context from the report

    “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported. ”

    Source location

    Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Deficiencies in pressure sore care planning and specialist referral

    Wider context from the report

    “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported. ”

    Source location

    Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inconsistent pressure sore risk scoring

    Wider context from the report

    “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported. ”

    Source location

    Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of nursing care to prevent and manage pressure sores

    Wider context from the report

    “(1) Infected pressure sores may have been a cause of death and they were unusual in extent and severity. Their development was prevented in ITU when he was most at risk and considerable improvement was achieved in the nursing home after discharge. Their development and deterioration related to nursing care on Murray Falconer ward in KCH between 27th September and 9th December. ”

    Source location

    Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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