Recurring concern

Failure to provide coordinated skin care across healthcare services

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First reported 27 Jul 2015•Latest report 11 Jun 2025

Definition

What this concern includes

Includes failures of the skin-care process across or within healthcare services, including coordination between Health Boards, primary care and hospital services, skin-integrity assessment, prevention, monitoring, treatment, referral and follow-up where these controls are specifically directed to protecting or managing patients' skin.

Not included

Excludes generic care coordination, communication or staffing deficiencies unless they directly concern skin care.
Excludes wound-management failures where the shared unsafe condition is management of a deteriorating wound rather than the broader coordination or delivery of skin care.
Excludes pressure-ulcer-specific prevention and treatment failures where the dedicated pressure-ulcer concern is the more specific supported boundary.
Excludes unrelated clinical assessments, referrals or deterioration concerns that do not materially involve skin care or skin integrity.

Reports: 7
Individual concerns: 9
Date range: 2015–2025
Stated actions: 38

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Aneurin Bevan University LHB1

Bargoed Care Home1

Bryntirion Surgery1

Care Quality Commission1

Central London Community Healthcare NHS Trust1

Court Nursing Home1

Croydon Health Services NHS Trust1

Cwm Taf Morgannwg University Local Health Board1

Happy at Home Community Care Services Ltd.1

Kapital Care (UK) Limited1

Office of the Chief Coroner1

Red Oaks Care Community1

Royal United Hospital1

Royal United Hospitals Bath NHS Foundation Trust1

Senedd Cymru1

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.

11 Jun2025
Nottinghamshire
Concerns raised1
1. Failure to conduct and record daily skin inspections
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Audit daily SSKIN inspection records through management-generated daily reports.
  Stated by Red Oaks Care HomeStated completed
2. Action
  Conduct weekly and monthly management audits of pressure-care records, actions, professional input, care plans and risk assessments.
  Stated by Red Oaks Care HomeStated completed
Respondent positions 1
1. Position
  The strengthened systems and procedures for monitoring residents’ care arrangements are considered appropriate in all the circumstances.
  Stated by Red Oaks Care HomeExisting arrangements considered sufficient
AI-generated summary

Maureen POWELL · 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

Maureen Powell died from severe frailty after a prolonged period of ill health, hospitalisation and transfer to a nursing home. A serious pressure ulcer developed and worsened in the nursing home and contributed to her death. Concerns included inadequate recording and implementation of repositioning, failure to record skin inspections, delayed equipment and specialist referral, poor record-keeping, inaccurate reporting, and insufficient communication with her family.

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 conduct and record daily skin inspections
Wider context from the report
“2. There was widespread non-compliance with the regime of daily skin inspections in the period of time that Maureen was a resident at the Nursing Home. Not one skin inspection was recorded during Maureen’s stay; ”
Source location
Maureen POWELL · 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
Audit daily SSKIN inspection records through management-generated daily reports.

Verbatim wording from the response
“• Care staff are required to complete SSKIN Inspections Records every 24 hours, with any concerns reported to the Registered Nurse on duty. The SSKIN Inspection Records are now in turn audited by management upon the generation of daily reports.”

Source location
Response from Red Oaks Care Home
Page 2 · response
Published 19 June 2025
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
Conduct weekly and monthly management audits of pressure-care records, actions, professional input, care plans and risk assessments.

Verbatim wording from the response
“• Weekly and monthly audits are conducted by management in relation to care records relating to residents’ pressure care and skin integrity, for the purpose of ensuring that all actions have been completed in a timely manner, any external professional input required has been sought accordingly, and that care plans and risk assessments have been reviewed and updated as appropriate.”

Source location
Response from Red Oaks Care Home
Page 2 · response
Published 19 June 2025
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 strengthened systems and procedures for monitoring residents’ care arrangements are considered appropriate in all the circumstances.

Verbatim wording from the response
“Accordingly, significant steps have been taken by the Home to strengthen the systems and procedures in place to monitor the correct implementation of care arrangements for residents, which are considered to be appropriate in all the circumstances.”

Source location
Response from Red Oaks Care Home
Page 4 · response
Published 19 June 2025
Open published response
30 Aug2024
Berkshire
Concerns raised1
1. Inadequate training in monitoring skin integrity
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Wendy Ann AFFORD · 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

Wendy Ann Afford was bedbound and living alone with a package of care before developing worsening pressure damage and an infected pressure ulcer. After hospital treatment and discharge to a care home, her health declined and she died on 15 November 2023. Concerns included inadequate skin-integrity risk assessment and monitoring, incomplete repositioning records, unclear compliance with care plans, insufficient management oversight, and possible inadequate staff training.

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
Inadequate training in monitoring skin integrity
Wider context from the report
“5. Given these numerous difficulties there is a concern that care staff are not properly trained in the use of care plans, record keeping and importance of monitoring skin integrity. ”
Source location
Wendy Ann AFFORD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Jul2023
Avon
Concerns raised1
1. Failure to perform accurate daily skin assessments
This report raised 14 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 4
1. Action
  Deliver face-to-face pressure-ulcer prevention and management training to substantive nursing, physiotherapy and occupational therapy staff.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated completed
2. Action
  Complete and monitor staff workbooks assessing knowledge and skills in pressure-ulcer prevention and management.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated in progress
3. Action
  Pilot a bespoke tissue-viability monitoring tool capturing patient experience, outcomes and documentation compliance.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated in progress
1. Action
  Implement actions to improve documentation-audit compliance to 95%.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated in progress
AI-generated summary

Alan Christopher NIPPARD · 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

Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.

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 perform accurate daily skin assessments
Wider context from the report
“I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with. There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking. It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired. That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight. I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including: • That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly. • On the MAU he did not have his risk assessment done within 6 hrs as it should have been. • It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress. • Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay. • Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved. • The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed. • Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t. • On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation • Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all. • It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been. • When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly. • It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved • There was no evidence of the use of 2 sliding sheets to assist with moving him. • On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all. • Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable. • Fluid balance charts were poorly completed. • He wasn’t weighed which would have assisted with managing his oedema. • Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care. I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team. ”
Source location
Alan Christopher NIPPARD · Prevention of Future Deaths report
Page 3 · 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
Deliver face-to-face pressure-ulcer prevention and management training to substantive nursing, physiotherapy and occupational therapy staff.

Verbatim wording from the response
“Since the inquest into Mr Nippard’s death, the Tissue Viability Nursing (TVN) Team have led a programme of face to face training for all substantive members of nursing staff on Pierce Ward. In addition, all Physiotherapists and Occupational Therapists have also received training.”

Source location
Response from Royal United Hospitals Bath NHS Foundation Trust
Page 1 · response
Published 4 August 2023
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
Complete and monitor staff workbooks assessing knowledge and skills in pressure-ulcer prevention and management.

Verbatim wording from the response
“The training has focussed on addressing the learning from incidents which includes; consistently undertaking appropriate skin assessments, repositioning and the correct use of equipment. The training also incorporated training on the nationally recognised SKIN bundle which stands for ‘skin, surface, keep moving, incontinence, nutrition and hydration’ in addition to risk assessments, care planning, reporting and escalation. Staff knowledge and skills has been assessed using a workbook which has been distributed to and completed by each staff member. At the time of responding, 5 have not yet completed their work book which is being monitored and full compliance is expected.”

Source location
Response from Royal United Hospitals Bath NHS Foundation Trust
Page 1 · response
Published 4 August 2023
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
Pilot a bespoke tissue-viability monitoring tool capturing patient experience, outcomes and documentation compliance.

Verbatim wording from the response
“A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and actions are in place to achieve 95%.”

Source location
Response from Royal United Hospitals Bath NHS Foundation Trust
Page 1 · response
Published 4 August 2023
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 actions to improve documentation-audit compliance to 95%.

Verbatim wording from the response
“A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and actions are in place to achieve 95%.”

Source location
Response from Royal United Hospitals Bath NHS Foundation Trust
Page 1 · response
Published 4 August 2023
Open published response
5 Dec2022
Inner North London
Concerns raised3
1. Failure to issue and disseminate daily skin-integrity checking instructions to all carers
2. Omission of daily skin-integrity checking instruction from discharge assessment form
3. Failure to establish daily skin-integrity monitoring responsibility
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 29
1. 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 completed
2. 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 completed
3. 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 completed
1. 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 completed
2. Action
  Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training standards.
  Stated by Central London Community Healthcare NHS TrustStated completed
3. Action
  Offer additional pressure-ulcer prevention training to care organisations where required.
  Stated by Central London Community Healthcare NHS TrustStated planned
4. 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 completed
5. 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 progress
6. 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 planned
7. 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 planned
8. Action
  Provide refresher pressure-ulcer management training where appropriate.
  Stated by Kapital Care (UK) LimitedStated planned
9. 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 completed
10. 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 progress
11. Action
  Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.
  Stated by Kapital Care (UK) LimitedStated completed
12. Action
  Review organisational recording and documentation practices.
  Stated by Kapital Care (UK) LimitedStatus unclear
13. Action
  Obtain the relevant discharge notification form before starting hospital-discharge care packages.
  Stated by Kapital Care (UK) LimitedStated planned
14. 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 progress
15. Action
  Establish a dedicated telephone number and contact time for discussing hospital discharges.
  Stated by Central London Community Healthcare NHS TrustStated completed
16. Action
  Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.
  Stated by Central London Community Healthcare NHS TrustStated completed
17. Action
  Set up a dedicated telephone line and contact time for nurses to discuss hospital discharges.
  Stated by Central London Community Healthcare NHS TrustStated completed
18. Action
  Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.
  Stated by Central London Community Healthcare NHS TrustStated completed
19. Action
  Share discharge communications and care plans with all providers involved in patients’ care.
  Stated by Central London Community Healthcare NHS TrustStated completed
20. Action
  Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
21. Action
  Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
22. Action
  Ensure robust and timely communication with all agencies involved in care arrangements.
  Stated by Kapital Care (UK) LimitedStated in progress
23. Action
  Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
24. Action
  Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
25. Action
  Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.
  Stated by University College London Hospitals NHS Foundation TrustStated planned
26. Action
  Contact district nurses whenever they are involved in an adult’s care arrangements.
  Stated by Kapital Care (UK) LimitedStated planned
Respondent positions 1
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 sufficient
AI-generated summary

Richard Thomas SHANNON · 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

Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.

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 issue and disseminate daily skin-integrity checking instructions to all carers
Wider context from the report
“3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction. Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice. Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer. ”
Source location
Richard Thomas SHANNON · Prevention of Future Deaths report
Page 3 · 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
Omission of daily skin-integrity checking instruction from discharge assessment form
Wider context from the report
“4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission. ”
Source location
Richard Thomas SHANNON · Prevention of Future Deaths report
Page 4 · 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 establish daily skin-integrity monitoring responsibility
Wider context from the report
“2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all. ”
Source location
Richard Thomas SHANNON · Prevention of Future Deaths report
Page 3 · 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
Update home-held care-plan templates with clear carer instructions, escalation criteria and community nurse contact details.

Verbatim wording from the response
“• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
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
Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.

Verbatim wording from the response
“• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
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
Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.

Verbatim wording from the response
“• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
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
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.

Verbatim wording from the response
“• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
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
Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training standards.

Verbatim wording from the response
“• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
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
Offer additional pressure-ulcer prevention training to care organisations where required.

Verbatim wording from the response
“• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations”

Source location
Response from Central London Community Healthcare
Page 3 · response
Published 8 December 2022
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
Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.

Verbatim wording from the response
“• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 8 December 2022
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
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.

Verbatim wording from the response
“• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).”

Source location
Response from University College London Hospitals
Page 5 · response
Published 8 December 2022
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
Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.

Verbatim wording from the response
“• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.”

Source location
Response from University College London Hospitals
Page 5 · response
Published 8 December 2022
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
Contact district nurses whenever they are involved in an adult’s care to incorporate pressure-ulcer and other relevant needs into care plans.

Verbatim wording from the response
“• Kapital Care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.”

Source location
Response from Kapital Care
Page 1 · response
Published 8 December 2022
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
Provide refresher pressure-ulcer management training where appropriate.

Verbatim wording from the response
“• All care staff currently complete mandatory pressure ulcer management training. This has since been reviewed and staff will complete refresher training where appropriate.”

Source location
Response from Kapital Care
Page 1 · response
Published 8 December 2022
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
Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.

Verbatim wording from the response
“• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient’s notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 2022
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
Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.

Verbatim wording from the response
“• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).”

Source location
Response from University College London Hospital
Page 5 · response
Published 8 December 2022
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
Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.

Verbatim wording from the response
“• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.”

Source location
Response from Kapital Care
Page 2 · response
Published 8 December 2022
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
Review organisational recording and documentation practices.

Verbatim wording from the response
“• Review of recording and documentation within the organisation.”

Source location
Response from Kapital Care
Page 2 · response
Published 8 December 2022
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
Obtain the relevant discharge notification form before starting hospital-discharge care packages.

Verbatim wording from the response
“• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.”

Source location
Response from Kapital Care
Page 3 · response
Published 8 December 2022
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 the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.

Verbatim wording from the response
“• The local authority has introduced a new Hospital Discharge Reablement Assessment Form. Implementation has begun and will be fully embedded by 6th February 2023. The new form includes prompts and mandatory fields in medical areas such as pressure care, manual handling, and medication. This information is transferred to the care plan sent to care agencies delivering social care. This tool is in operational use locally and is required to be shared across agencies.”

Source location
Response from City of Westminster
Page 2 · response
Published 8 December 2022
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
Establish a dedicated telephone number and contact time for discussing hospital discharges.

Verbatim wording from the response
“• We have enhanced lines of communication between our teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.”

Source location
Response from Central London Community Healthcare
Page 1 · response
Published 8 December 2022
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
Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.

Verbatim wording from the response
“• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.”

Source location
Response from Central London Community Healthcare
Page 1 · response
Published 8 December 2022
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
Set up a dedicated telephone line and contact time for nurses to discuss hospital discharges.

Verbatim wording from the response
“• We have enhanced lines of communication between our teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.”

Source location
Response from Central London Community Healthcare
Page 1 · response
Published 8 December 2022
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
Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.

Verbatim wording from the response
“• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.”

Source location
Response from Central London Community Healthcare
Page 1 · response
Published 8 December 2022
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
Share discharge communications and care plans with all providers involved in patients’ care.

Verbatim wording from the response
“• All communications including care plans are now being shared with all providers involved in care at discharge to ensure consistency in care provision.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
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
Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.

Verbatim wording from the response
“• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 8 December 2022
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
Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.

Verbatim wording from the response
“• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 8 December 2022
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
Ensure robust and timely communication with all agencies involved in care arrangements.

Verbatim wording from the response
“• Kapital care is ensuring robust and timely communication is undertaken with all agencies.”

Source location
Response from Kapital Care
Page 3 · response
Published 8 December 2022
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
Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.

Verbatim wording from the response
“• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 2022
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
Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.

Verbatim wording from the response
“• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 2022
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
Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.

Verbatim wording from the response
“• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 2022
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
Contact district nurses whenever they are involved in an adult’s care arrangements.

Verbatim wording from the response
“• Kapital care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.”

Source location
Response from Kapital Care (UK) Limited
Page 1 · response
Published 8 December 2022
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
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.

Verbatim wording from the response
“We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.”

Source location
Response from University College London Hospitals
Page 6 · response
Published 8 December 2022
Open published response
1 Sep2021
South London
Concerns raised1
1. Lack of skin integrity assessments and preventive measures in A&E
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Roll out the agreed pressure-ulcer prevention actions across the organisation.
  Stated by Croydon Health Services NHS TrustStated completed
2. Action
  Place monitoring and evaluation of the actions on the monthly pressure-ulcer prevention meeting agenda for at least three months.
  Stated by Croydon Health Services NHS TrustStated planned
3. Action
  Cascade pressure-ulcer prevention initiatives and new actions effectively across all clinical departments.
  Stated by Croydon Health Services NHS TrustStated planned
AI-generated summary

John Willis Humphries · 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

John Willis Humphries was admitted to hospital with abdominal pain and developed pressure sores, which deteriorated during his stay. He was later readmitted, developed recurrent urinary tract infections associated with catheterisation, and died from pulmonary oedema and pneumonia. Concerns included the absence of reported skin integrity assessments or measures in the Emergency Department and the failure to seek advice on managing his resistance to repositioning.

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 skin integrity assessments and preventive measures in A&E
Wider context from the report
“(1) I heard evidence that Mr Humphries’ pressure sore probably started in A&E where he stayed for a long period before being moved to a ward. I was not informed of any skin integrity assessments or measures whilst he was in A&E. ”
Source location
John Willis Humphries · 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
Roll out the agreed pressure-ulcer prevention actions across the organisation.

Verbatim wording from the response
“6. Agreed Actions: Although there was a particular focus in the Emergency Department and Fairfield 1 in response to this PFD the actions have been rolled out across the organisation.”

Source location
2021-0291-Response-from-Croydon-Health-Services-NHS-Trust
Page 1 · response
Published 9 September 2021
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
Place monitoring and evaluation of the actions on the monthly pressure-ulcer prevention meeting agenda for at least three months.

Verbatim wording from the response
“5. Response of Pressure Ulcer Reduction group: Following the receipt of the PFD the Organisations Pressure Ulcer Prevention group met on the 22nd September 2021 to discuss and review the immediate actions but in place by the Associate Director of Nursing as an immediate response to the notification.”

Source location
2021-0291-Response-from-Croydon-Health-Services-NHS-Trust
Page 1 · response
Published 9 September 2021
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
Cascade pressure-ulcer prevention initiatives and new actions effectively across all clinical departments.

Verbatim wording from the response
“• Communication of all the initiatives and new actions from the Pressure Ulcer prevention group to be effectively cascades to all departments”

Source location
2021-0291-Response-from-Croydon-Health-Services-NHS-Trust
Page 2 · response
Published 9 September 2021
Open published response
16 Jan2021
Nottinghamshire
Concerns raised1
1. Failure to maintain an updated skin integrity care plan
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Norma Lockton · 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

Norma Lockton was a resident in a nursing home whose reduced mobility and vulnerable skin required care measures that were not followed. She developed a wound behind her left knee, which became infected and led to cellulitis and systemic sepsis; medical assistance was not sought until her condition was life threatening, and she died in hospital on 4 March 2020. The principal concerns included failures in skin care planning and implementation, repositioning, recognition of changing care needs and deteriorating health, and management review following the death.

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 an updated skin integrity care plan
Wider context from the report
“1. The lack of an updated skin integrity care plan, with little understanding by the management as to why there had been no update to it following the clear District Nurse instructions regarding skin care. ”
Source location
Norma Lockton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Lack of integrated skin care across Health Boards and Primary healthcare services
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.
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
Lack of integrated skin care across Health Boards and Primary healthcare services
Wider context from the report
“(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services. ”
Source location
Mr. Arthur Cook · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to conduct and record daily skin inspections

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Inadequate training in monitoring skin integrity

Concerns raised1

Failure to perform accurate daily skin assessments

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

Concerns raised3

Failure to issue and disseminate daily skin-integrity checking instructions to all carers

Omission of daily skin-integrity checking instruction from discharge assessment form

Failure to establish daily skin-integrity monitoring responsibility

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.29

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 2

Respondent positions 1

Actions described in response 4

Actions described in response 29

Respondent positions 1