Recurring concern

Insufficient tissue viability service capacity and access

First to latest report 19 Dec 2014 — 25 Sep 2025

Reports that mention this concern
9
Times this concern has been raised
11
Stated actions linked to this concern
6

What this concern includes

Includes failures in the named tissue viability service or team that limit timely provision according to need, including insufficient Tissue Viability Nurse staffing, withdrawal or absence of embedded tissue viability provision, unavailable weekend access and resulting delays in specialist assessment or support.

What is not included
  • Excludes generic healthcare, district nursing or care-home staffing shortages where tissue viability service capacity or access is not the identified unsafe condition.
  • Excludes failures in wound care, pressure-ulcer prevention, referral guidance or follow-up where tissue viability service capacity or access is not materially deficient.
  • Excludes failures occurring after timely tissue viability input has been provided, including unrelated implementation or documentation failures.
  • Excludes generic specialist-service shortages without an explicit tissue viability service or team connection.

Reports and published responses 9 reports

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

  1. Essex

    AI-generated summary

    Susan Margaret Barrett · 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

    Susan Margaret Barrett died on 30 July 2024 from sepsis arising from osteomyelitis caused by a Grade 4 sacral pressure ulcer, against a background of dementia. The ulcer deteriorated during and after hospital care, with communication failures contributing to at least a two-month delay in daily nursing care. Concerns were also raised about the absence of embedded Tissue Viability Nurses or a Tissue Viability Service across community hospital wards and the resulting risk to vulnerable patients.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Absence of embedded, dedicated Tissue Viability Nurses and a Tissue Viability Service across Community Hospital Wards

    Wider context from the report

    “However, serious concerns were raised in evidence by East Suffolk and North Essex NHS Foundation Trust (ESNEFT) witnesses relating to the impact and consequences of an absence of embedded, dedicated Tissue Viability Nurses (TVNs) and a Tissue Viability Service (TVS) across the two ESNEFT Community Hospital Sites which, together, involve three Wards (including Trinity Ward) with, cumulatively, some 77 patient beds. The Community Hospital Wards are Nurse Practitioner led and based on a GP model but since 2023 have seen the withdrawal of embedded TVNs or a TVS across all Wards. The evidence from both the Colchester General Hospital Matron and the Community Tissue Viability Lead Nurse confirmed that whilst this has been formally recognised as a ‘risk’ - and attempts at mitigation have been attempted - the steps taken have been inadequate. In her evidence the Tissue Viability Lead Nurse confirmed that she had raised and escalated her concerns regarding the change in policy and informed the Court that she had felt it necessary to “block” some transfers of vulnerable patients from the Acute Hospital to the Community Hospital, expressly on the basis that the absence of an embedded TVS gave rise to a serious risk of the deterioration of these frail and vulnerable patients’ pressure ulcers to the extent, she confirmed, that such transfers presented a risk of future deaths. Notwithstanding the ‘blocking’ she has been required to resort to, she made reference to an increase in pressure damage in the Community Hospital Wards in a 2025 three month period compared to the same period in 2024. ”

    Source location

    Susan Margaret Barrett · 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

    Fund and approve establishment of a substantive 0.6 WTE Band 6 Tissue Viability CNS post.

    Verbatim wording from the response

    “The Medicine and Community Services North East Essex division within the Trust have confirmed funding for 0.6wte Band 6 Tissue Viability CNS as a substantive post.”

    Source location

    Response from East Suffolk and North Essex NHS Foundation Trust
    Page 1 · response
    Published 21 November 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

    Recruit a 0.6 WTE Band 6 Tissue Viability CNS to provide tissue viability services across community hospital sites.

    Verbatim wording from the response

    “RECRUITMENT OF ADDITIONAL TVN RESOURCE TO EMBED A TVS ACROSS COMMUNITY HOSPITAL SITES”

    Source location

    Response from East Suffolk and North Essex NHS Foundation Trust
    Page 1 · response
    Published 21 November 2025

    Open published response

  2. Manchester South

    AI-generated summary

    George Neville Coulthard · 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

    George Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care support.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Limited access to tissue viability and district nursing information and support for wound care in the community

    Wider context from the report

    “4. The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited. Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However the demands across GM on TVN and DN services made this difficult to achieve. ”

    Source location

    George Neville Coulthard · 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

    Demand across Greater Manchester tissue viability and district nursing services made improved community wound-care access difficult to achieve.

    Verbatim wording from the response

    “The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited. Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However, the demands across GM on TVN and DN services made this difficult to achieve.”

    Source location

    Response from GMIC
    Page 6 · response
    Published 24 September 2024

    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

    Limited access to community tissue viability and district nursing wound care falls outside the regulator’s remit.

    Verbatim wording from the response

    “We have considered this point and have concluded that, this regretfully sits outside of CQC remit. We believe the Secretary of State and Greater Manchester Integrated Care will be of greater assistance in addressing this aspect of your concerns.”

    Source location

    Response from CQC
    Page 5 · response
    Published 24 September 2024

    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 Secretary of State and Greater Manchester Integrated Care are considered better placed to address limited community wound care access.

    Verbatim wording from the response

    “We have considered this point and have concluded that, this regretfully sits outside of CQC remit. We believe the Secretary of State and Greater Manchester Integrated Care will be of greater assistance in addressing this aspect of your concerns.”

    Source location

    Response from CQC
    Page 5 · response
    Published 24 September 2024

    Open published response

  3. Staffordshire and Stoke-on-Trent

    AI-generated summary

    Myra Maxfield · 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

    Myra Maxfield, aged 89, fell at home, fractured her right hip, and subsequently developed a Grade 4 pressure sore and osteomyelitis. She died in hospital on 12 March 2022 following a further upper gastrointestinal bleed; concerns included delays in pressure-ulcer patients being assessed by the Tissue Viability Team and the lack of weekend availability at Royal Stoke University Hospital.

    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

    Unavailability of Tissue Viability Team over weekends causing delays in patient assessment

    Wider context from the report

    “1. Evidence emerged during the inquest that it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours. 2. It was said that, delays in doing so, could be causative in the death of patients. 3. Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend, and this leads to substantial delay in patients being seen. ”

    Source location

    Myra Maxfield · 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

    Monitor Specialist Tissue Viability Team referral-to-response times according to pressure-ulcer severity.

    Verbatim wording from the response

    “In response to your concerns, we will continue to monitor the timeliness of pressure ulcer risk assessment completion by our Ward/Department teams via our monthly Tendable Care Excellence audits. We will also ensure that the referral criteria for Ward/Department Teams to refer patients to the Tissue Viability Team for specialist advice and support is reviewed and included in UHNМ Trust Policy C63, Prevention and Management of Pressure Ulcers. We will subsequently monitor referral to response times, according to the severity of the Pressure Ulcer, by our Specialist Tissue Viability Team.”

    Source location

    Response from University Hospitals of North Midlands
    Page 3 · response
    Published 31 October 2023

    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

    NICE or the National Wound Care Strategy Programme should be engaged because no specific guidance sets tissue viability referral timings.

    Verbatim wording from the response

    “There are no specific guidelines for when patients should be referred to a Tissue Viability Specialist (TVS) within the NICE guidance or in the international best practice guidelines. You may wish to engage with NICE or the NWCSP regarding this issue.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 October 2023

    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 relevant NHS Trust is responsible for commenting on tissue viability provision at Royal Stoke University Hospital.

    Verbatim wording from the response

    “NHS England is not able to provide comment on the provision of the service specifically within Royal Stoke University Hospital and would refer you to the Trust on this issue.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 October 2023

    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 applicable six-hour requirement is for pressure-ulcer risk assessment, not review by the Specialist Tissue Viability Team.

    Verbatim wording from the response

    “1. As a point of clarification on the issues that you have raised in Point 1 of your letter, regarding the fact that ‘it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours’.”

    Source location

    Response from University Hospitals of North Midlands
    Page 2 · response
    Published 31 October 2023

    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

    Routine weekend Tissue Viability coverage is unnecessary because pathways, policies, guidance and staff training mitigate pressure-ulcer risks out of hours.

    Verbatim wording from the response

    “We strive to provide a high standard of care to all of our patients and preventing avoidable pressure ulcers and managing existing pressure ulcers, as in the case of Mrs Maxfield, is an important quality metric. People in hospital can be at higher risk of pressure ulcer damage but we have a range of support for teams to minimise the risk of pressure ulcer development or deterioration. UHNМ provide a regular 5-Day (Monday – Friday) Tissue Viability Service, which is in line with most acute Trusts nationally. However, as demonstrated in the case of Mrs Maxwell, a limited service is provided at weekends in extenuating circumstances and on an ad hoc basis.”

    Source location

    Response from University Hospitals of North Midlands
    Page 3 · response
    Published 31 October 2023

    Open published response

  4. Manchester North

    AI-generated summary

    Christopher Byron · 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

    Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Shortage of staff within the Tissue Viability Nurse team

    Wider context from the report

    “3. Shortage of staff. One of the reasons there was a lack of continuity in the care of Mr Byron was the shortage of staff and the increased workload on the remaining staff. The Court was advised there remains a shortage of staff within the Tissue Viability Nurse team. ”

    Source location

    Christopher Byron · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Norfolk

    AI-generated summary

    Carol Anne JENNINGS · 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

    Carol Anne Jennings had multiple comorbidities and was admitted to hospital on 10 January 2019. She developed infected leg ulcers, deteriorated, began end-of-life care on 25 January, and died on 31 January 2019; the inquest recorded septicaemia, infected leg ulcers and hospital-acquired pneumonia as the medical causes of death. Concerns included the handling and follow-up of a Tissue Viability Nurse referral and inadequate wound record keeping.

    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

    Insufficient Tissue Viability Nurse capacity to deal with referrals

    Wider context from the report

    “1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward. A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented. ”

    Source location

    Carol Anne JENNINGS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Surrey

    AI-generated summary

    Ronald Arthur Farrington · 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

    Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.

    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 tissue viability nurse service capacity

    Wider context from the report

    “2. Only one tissue viability nurse was employed by First Community Care from March 2016 onwards. They were on annual leave for 6 weeks between the 18th March and the 15th June 2016. This was not an adequate level of service. ”

    Source location

    Ronald Arthur Farrington · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Bedfordshire and Luton

    AI-generated summary

    Jean Marjorie McHALE · 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

    Jean Marjorie McHALE was admitted to hospital in July 2016 with confusion, fever, poor general health and two Grade 4 pressure sores. The inquest concluded that she died from sepsis from infected pressure ulcers. Concerns included inadequate treatment of pressure ulcers, insufficient Tissue Viability Nurse provision, and the need for an urgent review.

    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

    Insufficient Tissue Viability Nurse staffing in community and hospital settings

    Wider context from the report

    “(2) That there are not enough Tissue Viability Nurses working in the community or in the hospital to meet the needs of the patients ”

    Source location

    Jean Marjorie McHALE · 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

    Complete a review of the community tissue viability nursing service.

    Verbatim wording from the response

    “In response to these, a service review has been undertaken. On reviewing the TVN service within the Trust, we can confirm that clear pathways are in place to ensure timely and effective referral to the service and we have increased the provision of TVN’s available over the past two years. Further to this, the community nurses, although they are not TVNs, do have ongoing training and monitoring to ensure they are skilled in the prevention and early detection of pressure ulcers.”

    Source location

    2016-0456-Response-by-SEPT
    Page 1 · response
    Published 12 February 2017

    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

    Increase the provision of community tissue viability nurses.

    Verbatim wording from the response

    “In response to these, a service review has been undertaken. On reviewing the TVN service within the Trust, we can confirm that clear pathways are in place to ensure timely and effective referral to the service and we have increased the provision of TVN’s available over the past two years. Further to this, the community nurses, although they are not TVNs, do have ongoing training and monitoring to ensure they are skilled in the prevention and early detection of pressure ulcers.”

    Source location

    2016-0456-Response-by-SEPT
    Page 1 · response
    Published 12 February 2017

    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

    Meet with Bedfordshire CCG to discuss reviewing commissioned community tissue viability nursing levels.

    Verbatim wording from the response

    “We have informed Bedfordshire CCG, who commissions our TVN service, of the outcome of the inquest. As a result, we are meeting with them shortly to further discuss reviewing the commissioned levels of TVN service in the community.”

    Source location

    2016-0456-Response-by-SEPT
    Page 2 · response
    Published 12 February 2017

    Open published response

  8. 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

    Insufficient staffing of Tissue Viability Nurses

    Wider context from the report

    “(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need; ”

    Source location

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

    Open source report

  9. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mr. Thomas Jenkins · 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. Thomas Jenkins developed pressure sores while receiving care after a cerebrovascular accident, including an infected chronic pressure sore on his right heel. He was readmitted to hospital and died of sepsis on 8 August 2014. The principal concern was inadequate and delayed tissue viability nursing and wound care input, attributed to specialist nurses not being based in the hospital and insufficient staffing across the region.

    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 Tissue Viability Nurse and wound care input

    Wider context from the report

    “(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”

    Source location

    Mr. Thomas Jenkins · 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

    Insufficient Tissue Viability Nurse capacity to serve the regional hospitals

    Wider context from the report

    “(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”

    Source location

    Mr. Thomas Jenkins · 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

    Specialist nurses not being based in the hospital for TVN and wound care input

    Wider context from the report

    “(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”

    Source location

    Mr. Thomas Jenkins · Prevention of Future Deaths report
    Page 2 · 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