Recurring concern
Inadequate management of pressure ulcers
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Request correctionFirst reported 20 Aug 2013•Latest report 12 Mar 2026
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
- Individual concerns
- 106
- Date range
- 2013–2026
- Stated actions
- 135
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of risk assessment for falls and pressure sore risk
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 concernsEach 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
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Action
Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.
Stated by Lambton House
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Concerns raised3
Delays in referral to Tissue Viability Nurses
Failure to follow Tissue Viability Nurses advice
Failure to provide an upgraded mattress
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of nighttime care provision for patients requiring regular turning
Responses linked to these concernsEach 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.3
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Action
Operate a Community Pressure Ulcer Panel to review causes and risk factors and ensure adequate care, interventions and protection arrangements.
Stated by NHS Lewisham Clinical Commissioning Group -
Action
Support patients discharged to family care and arrange alternatives, including continuing healthcare assessment, when families cannot provide adequate support.
Stated by NHS Lewisham Clinical Commissioning Group -
Action
Monitor discharge support and alternative arrangements through contract management at the Clinical Quality Review Group.
Stated by NHS Lewisham Clinical Commissioning Group
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Concerns raised5
Failure to verify correct pressure mattress function
Inadequate staff training in pressure mattress management
Failure to record identified pressure mattress faults
Failure to carry out pressure sore repositioning plans
Falsification of pressure sore repositioning records
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Share investigation learning with New Park House and recommend improvements to recording practices.
Stated by Stoke-on-Trent City Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.
Stated by Stoke-on-Trent City Council
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Position
The investigation found no evidence that the pressure-sore management plan was inadequately followed or that records had been falsified.
Stated by Stoke-on-Trent City Council
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Concerns raised1
Failure to maintain adequate pressure ulcer documentation
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised4
Lack of staff knowledge about pressure sore formation and prevention
Failure to provide staff training on pressure sore formation and prevention
Failure to prepare care plans for patients at high risk of pressure sore formation
Inadequate RMN training on pressure sores
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 concernsEach 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
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Position
Birmingham Cross City CCG commissions the service and is undertaking work to address the identified care deficiencies.
Stated by NHS England
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Position
Responsibility for setting nursing curricula and training standards rests with the Nursing and Midwifery Council, not Health Education England.
Stated by Department of Health and Social Care
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Concerns raised1
Pressure damage to the hips and buttocks
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of ready access to necessary dressings for nursing homes and Community Nurses treating pressure sores
Responses linked to these concernsEach 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
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Action
Implement a stock box and first-dressing system for patients beginning care.
Stated by Sussex Community NHS Foundation Trust -
Action
Implement an escalation process for delays in dressing-supply responses.
Stated by Sussex Community NHS Foundation Trust -
Action
Run the ONPOS ordering service in shadow mode for six to twelve months.
Stated by Sussex Community NHS Foundation Trust
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Action
Roll out the ONPOS ordering service fully after the shadow period.
Stated by Sussex Community NHS Foundation Trust -
Action
Investigate the delay in ordering dressings and the application and use of non-prescribed dressings through the Deputy Chief Nurse.
Stated by Coastal West Sussex Clinical Commissioning Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The pharmacy did not delay processing the dressings order.
Stated by Coastal West Sussex Clinical Commissioning Group
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Position
The prescription request delay was not detrimental because appropriate dressings were available from residential home stock.
Stated by Coastal West Sussex Clinical Commissioning Group
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Concerns raised1
Failure to identify patients with relevant co-morbidities as higher risk
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Lack of a pressure-relieving mattress at discharge home
Discharge home with severe pressure sores
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 concernsEach 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
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Action
Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Data last updated 7 September 2026