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
Insufficient access to appropriate dressings for severe pressure sores
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 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
Failure to seek medical attention for patients’ pressure sores
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 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 an alarm or other warning for developing air-mattress deflation
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
Replace community Nimbus systems with the fully alarmed Elite mattress system.
Stated by Cornwall Council
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Concerns raised3
Use of a non-patient-specific mattress
Use of non-patient-specific dressings for pressure sores
Lack of a pressure sore prevention and care policy
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 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
The mattress provided was not shown to be incorrect or improperly used.
Stated by Southwinds Limited
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Position
The dressing applied for comfort was not shown to be incorrect.
Stated by Southwinds Limited
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Concerns raised1
Failure to refer infected pressure sores to a general practitioner
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Use of pressure sore risk tools with opposing score interpretations
Failure of the pressure sore risk tool to account for existing lesions
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
Keep use of the Braden tool under ongoing review against national guidance and standards.
Stated by Avery Healthcare 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 wound would likely have deteriorated regardless of the pressure-ulcer risk assessment tool because repositioning was not tolerated and mobility was reduced.
Stated by Avery Healthcare Group
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Position
The Braden tool, existing systems and staff training are considered effective, so its use will continue while remaining under ongoing review.
Stated by Avery Healthcare Group
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Concerns raised2
Delay in informing treating clinicians about hospital-acquired grade 3 pressure sores
Failure to refer hospital-acquired grade 3 pressure sores to the tissue viability nurse
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 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 documentation recording pressure-sore treatment measures
Lack of turning charts for pressure-sore care
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.2
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Action
Maintain individual resident folders containing daily care records, including repositioning charts.
Stated by The Grange Care Centre Cheltenham -
Action
Require the responsible nurse to sign off each chart before evening handover and record additional notes.
Stated by The Grange Care Centre Cheltenham
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Although a robust system was not then in place, relevant records for Mr White existed, qualifying the concern about missing documentation.
Stated by The Grange Care Centre Cheltenham
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Concerns raised2
Delays in completing Waterloo pressure-risk scoring
Failure to ensure timely provision and use of pressure-relieving equipment
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
Failure to appropriately treat pressure ulcers in elderly people in the community
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.4
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Action
Complete a review of the community tissue viability nursing service.
Stated by Trust -
Action
Maintain clear referral pathways for timely access to tissue viability nursing services.
Stated by Trust -
Action
Increase the provision of community tissue viability nurses.
Stated by Trust
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Action
Investigate all category 3 and 4 pressure ulcers through root-cause analysis and Skin Matters panels to identify learning.
Stated by Trust
Data last updated 7 September 2026