Recurring concern

Failure to reliably conduct and record skin inspections

First to latest report 24 Aug 2021 — 11 Jun 2025

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
10

What this concern includes

Includes failures to conduct, repeat when clinically indicated, record or retain required skin inspections and their findings for vulnerable or care-dependent people, including daily inspections, increased-frequency inspections after skin changes or ulcers, and comparable inspection records across care settings.

What is not included
  • Excludes broader pressure-ulcer prevention or treatment failures where skin inspection is not the deficient control.
  • Excludes generic clinical-record deficiencies where the underlying skin inspection was completed and the problem is unrelated to recording or retention.
  • Excludes general personal hygiene, continence care, wound treatment or nutrition failures unless they directly concern the required skin-inspection process.
  • Excludes isolated undocumented observations where no continuing or system-level failure of skin inspection or its recording is identified.

Reports and published responses 5 reports

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

  1. Nottinghamshire

    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

  2. Birmingham and Solihull

    AI-generated summary

    Sasha Honey MISHABI · 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

    Sasha Honey MISHABI died at Queen Elizabeth Hospital Birmingham on 18 April 2023 after a cardiac arrest followed by overwhelming bronchopneumonia. He had severe physical and mental health conditions and skin ulcers that were later determined not to have significantly contributed to his death. The inquest identified failures at St Andrew’s Healthcare to complete required pressure-ulcer risk assessments and skin inspections, record them adequately, report lesions, and provide appropriate oversight, as well as failures in governance and serious-incident investigation.

    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 carry out and adequately record required skin inspections

    Wider context from the report

    “1. Awareness of and compliance with St. Andrew's Healthcare 'Pressure Ulcer Prevention and Management' Policy Due to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure damage and ought to have had weekly waterlow assessments and daily skin inspections with more frequent assessment and inspection to be considered in the event of change such as the development of an ulcer. Statements were provided from ████████, Consultant Psychiatrist, and ████████, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The statements included information on Mr. Mishabi's waterlow assessment and skin inspections, and provided some records. At no time was it identified that the SAH 'Pressure Ulcer Prevention and Management Policy' was not followed in Mr. Mishabi's case. At inquest it was identified that ████████ had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it). The areas of non compliance identified at inquest were as follows: a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and 4.3 of the policy; b. failure to carry out and/or adequately record daily skin inspections in accordance with paragraph 4.4 of the policy; c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph 4.3 of the policy; d. failure to consider increasing the frequency of skin inspections and carry out and/or adequately record any skin inspections between the identification of ulcers on the 15th March 2023 and the admission to hospital on the 17th March 2023 in accordance with paragraph 4.4 of the policy; and e. failure to make a datix incident report when grade II lesions were identified on the 15th March 2023 in accordance with paragraph 4.7 of the policy; and f. failure to provide adequate monitoring and oversight of the implementation of the policy in Mr. Mishabi's case in accordance with paragraph 5 of the policy. . ”

    Source location

    Sasha Honey MISHABI · 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

    Implement a defined escalation process and daily huddle monitoring of Waterlow, Skin Bundle and NEWS2 assessments.

    Verbatim wording from the response

    “Change 4: Clear Escalation Plan and Daily Monitoring A well-defined escalation process in place to address any health needs promptly, with ward managers holding responsibility.”

    Source location

    Response from St Andrew's Healthcare
    Page 4 · response
    Published 6 November 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

    Although policy documentation was deficient, existing pressure-ulcer prevention measures were already in place and had no effect on the care available.

    Verbatim wording from the response

    ““Mr Mishabi may have been prematurely discharged by colleagues at the QE on 2/04/23 as he was rapidly readmitted. Some liaison about how psych wards work and that the level of fitness required to be discharged to a psych ward being equivalent to that required to be managed in a domestic setting may be useful for QE colleagues going forwards.””

    Source location

    Response from St Andrew's Healthcare
    Page 2 · response
    Published 6 November 2023

    Open published response

  3. Avon

    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

  4. Sefton St Helens & Knowsley

    AI-generated summary

    Joan RICHARDSON · 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

    Joan RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.

    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 record skin integrity or breakdown in daily care records

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”

    Source location

    Joan RICHARDSON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Birmingham and Solihull

    AI-generated summary

    Peter Michael HARTE · 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

    Peter Michael HARTE died on 19 March 2021 in hospital after deterioration from multi-organ failure and sepsis caused by a bacterial skin infection and cellulitis. The principal concern was that skin inspections and monitoring in the care home between 14 and 18 March 2021 were not properly recorded, indicating a possible systemic failure in record-keeping and a risk to vulnerable residents.

    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 ensure that skin inspection observations are correctly and adequately recorded

    Wider context from the report

    “1. The evidence of ████████ suggested that proper skin inspections and skin monitoring were not carried out between 14th to 18th March 2021 as, had they been carried out, they would have been documented and recorded in detailed body maps. 2. The evidence of ████████ suggests that skin inspections were carried out but were not recorded. It was admitted by ████████ in evidence that there was a failure to keep proper and adequate records by staff. 3. At inquest I found that, on the balance of probabilities, inspections were carried out but observations were not recorded and records were not kept. 4. It was unclear whether this was a "one-off" incident or whether it reflected a systemic issue. On reflection, the fact that records were not taken or kept over a period of four consecutive days (as opposed to one isolated day), is indicative of a systemic issue that staff are not ensuring that their observations are correctly and adequately recorded. 5. It is clear that a failure to ensure that there is a correctly working system of record taking poses a risk of future deaths occurring, especially in the context of extremely frail and vulnerable adults/residents who in a position of dependency by virtue of their frailty or vulnerability. ”

    Source location

    Peter Michael HARTE · 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

    Provide all staff with feedback and support to follow body-mapping and care processes.

    Verbatim wording from the response

    “process. Documentation needs to be put in place. After coroner’s court I sat back and reflected on what was said and discussed with staff who had nursed peter, they felt they had provided good care to peter but found it very difficult to provide personnel care due to his behaviours. So throughout the days they ensured he received care in his best interest his personnel care, eating drinking and incontinent needs, which took many attempts on every occasion but our staff continued to ensure his well being and keep his dignity. Staff fully understand the importance of body maps and why we do them, but due to the difficult circumstance with peters challenging behaviour staff felt they couldn’t do anymore for peter than they already had.”

    Source location

    2021-0283-Response-from-Bromford-Lane-Care-Centre_Published
    Page 2 · response
    Published 26 August 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

    Commission and complete an external audit of body-map accuracy and timeliness.

    Verbatim wording from the response

    “Following this review, we have had an external auditor come and audit our body maps to ensure that they are being completed accurately for all service users. This identified that we are completing body maps in a timely manner and that staff are aware of the importance of skin integrity, how to check for concerns and how to report any concerns to the relevant staff member.”

    Source location

    2021-0283-Response-from-Bromford-Lane-Care-Centre_Published
    Page 2 · response
    Published 26 August 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

    Provide staff with suitable training, ongoing supervision and support as required.

    Verbatim wording from the response

    “We will of course continue to monitor the service quality and identify areas of improvement required and ensure that the staff are offered suitable training and ongoing supervision and support as required.”

    Source location

    2021-0283-Response-from-Bromford-Lane-Care-Centre_Published
    Page 2 · response
    Published 26 August 2021

    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

    Staff could not complete some body maps or provide further personal care because severe agitation and aggression prevented safe, effective interventions.

    Verbatim wording from the response

    “The staff who was looking after the peter on the days in question have explained that the peter was distressed, and they had done everything they could to reduce his distress and both nursing and care staff had tried to complete body maps however had been unsuccessful for some of the pre-existing wounds. However, the body maps for the 16/3/2021 18/3/21 had been completed where possible by the staff on the 15/3/21 and 17/3/2021 peter was non-compliant all day when staff approached peter, he bit punched and slapped them. so interventions were limited due to peters agitation but observations still took place. In the evidence pack provided to the coroner ABC charts was in place on both these days as peter was uncompliant with personnel care on both days. All staff have been spoken to and have received feedback and support to follow”

    Source location

    2021-0283-Response-from-Bromford-Lane-Care-Centre_Published
    Page 1 · response
    Published 26 August 2021

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026