Recurring concern

Failure to reliably reposition patients at required intervals

First to latest report 20 Aug 2013 — 26 Nov 2025

Reports that mention this concern
14
Times this concern has been raised
14
Stated actions linked to this concern
22

What this concern includes

Includes failures in arrangements for assessing, scheduling, performing, recording, monitoring and assuring required repositioning or turning of patients at specified intervals, including repositioning for pressure-damage prevention, respiratory care or other clinically identified needs.

What is not included
  • Excludes general pressure-ulcer prevention or treatment failures where no patient-repositioning deficiency is identified.
  • Excludes generic care staffing, training, documentation or audit failures unless they directly impair required patient repositioning or its assurance.
  • Excludes failures concerning mobility, moving and handling or patient positioning where repositioning at clinically required intervals is not the unsafe condition.
  • Excludes failures to act on pressure damage or respiratory deterioration after required repositioning has been reliably provided.

Reports and published responses 14 reports

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

  1. Birmingham and Solihull

    AI-generated summary

    Celia Marion PHILLIPS · 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

    Celia Marion PHILLIPS had a complex medical history and was bed bound, receiving care at home four times a day. She was admitted to hospital on 27 April 2025 with a probable chest infection, acute kidney injury and dehydration; a fractured ventriculo-peritoneal shunt had eroded through the skin and was protruding. She died on 1 May 2025 from multiple organ failure and sepsis of unknown origin, with the malfunctioning shunt contributing to her neurological decline and predisposing her to infection and dehydration. Concerns included a lack of evidence that she was repositioned or that carers had received training on pressure sores, skin assessment and repositioning, and she was found to have a deep tissue injury and a grade 1 pressure sore on admission.

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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

    Failure to undertake frequent repositioning of a bed-bound person

    Wider context from the report

    “1. The deceased was bed bound. 2. On the 12th March the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day. 3. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning. 4. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore. ”

    Source location

    Celia Marion PHILLIPS · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Explore working with Access Group to establish skin-check and repositioning options in daily digital records where needed.

    Verbatim wording from the response

    “– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

    Source location

    Response from Inspire You Care Ltd
    Page 2 · response
    Published 2 December 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Staff state that Celia was repositioned during all four daily care visits, despite repositioning not being recorded in daily logs.

    Verbatim wording from the response

    “– Staff stated that as mentioned before they did reposition Celia at all four daily visits as this would have to take place due to them having to complete personal care tasks for Celia at each visit.”

    Source location

    Response from Inspire You Care Ltd
    Page 2 · response
    Published 2 December 2025

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  2. Berkshire

    AI-generated summary

    Patrick Anthony COFFEY · 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

    Patrick Anthony Coffey fell at home, fractured multiple ribs, remained on the floor for about 17 hours, developed a chest infection and subsequently deteriorated in hospital. The report identified concerns that his pain was not always effectively controlled and that he was probably not repositioned every 2–4 hours as required, with gaps of up to 27 hours in the records; it stated that this posed a risk of future deaths in people with chest infections or at risk of pressure damage.

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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

    Failure to reposition patients every 2-4 hours

    Wider context from the report

    “I heard evidence that it was important that Mr Coffey spent most of his time in a seated position rather than lying down. This was to assist with his ability to breathe more deeply and cough more effectively; both of which are of importance when treating chest infections especially in the context of a patient with rib fractures. The nursing witness for the trust confirmed that Mr Coffey should have been repositioned every 2-4 hours. It had been identified by the hospital during random monthly audits that this was either not being done or not being properly recorded. Frimley Trust, after the inquest concluded, provided confirmation of when Mr Coffey’s position was recorded during his stay. These reveal that on certain days almost no information is recorded and on other days it is possible to know his position on a 2-4 hourly basis. Of particular note is the following: 1. There is no record of his position from 16.39 on the 15/9/2024 to 06.51 on the 16/09/24, 2. The only record between 19.11 on the 16/9/24 and 04.18 on the 18/9/24 is one entry at 06.23 on the 17/9/24 3. The only record between 22.26 on the 18/9/24 and 01.51 on the 20/9/24 is one entry at 10.34 on the 19/9/24 4. There are only 2 entries for the 22/9/24 at 06.06 & 22.11 5. The entries for the 24/9/24 cease at 14.08 and they do not restart until 12.24 on the 25/9/24 6. The last entry on the 25/9/24 is at 14.35 and the next entry is not until 17.59 on the 26/9/24 7. The final entry on the 26/9/24 is at 20.54 and the first entry on the 27/9/24 is at 10.03. These records therefore have gaps of up to 27 hours. In addition the vast majority of records that do exist do not reveal whether Mr Coffey was actually repositioned as only one position is recorded. It is only on about 7 or 8 occasions that a repositioning has been recorded. The medical records from the hospital do not show repositioning every 2-4 hours and I found that Mr Coffey was probably not repositioned as required. In the particular circumstances of Mr Coffey this did not contribute to his death lack of repositioning does give rise to a risk of future deaths of those suffering from chest infections or, indeed, those particularly at risk of pressure damage. ”

    Source location

    Patrick Anthony COFFEY · Prevention of Future Deaths report
    Page 1 · concerns

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    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

    Maintain system-driven EPR prompts that automatically trigger repositioning tasks at defined intervals and support ward- and patient-level auditing.

    Verbatim wording from the response

    “• While Purpose T recommends repositioning, it does not prompt it directly. Accordingly, we have worked with our electronic patient record (“EPR”) supplier EPIC to introduce task prompts at defined intervals, visible on the care plan interface to support compliance (as below). This work forms part of a broader pressure ulcer improvement programme aligned with the National Wound Care Strategy.”

    Source location

    Response from Frimley Health NHS Foundation Trust
    Page 2 · response
    Published 16 July 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver education sessions and ward-based support on repositioning documentation, risk assessment and effective EPIC use.

    Verbatim wording from the response

    “Education sessions have also been delivered, and in addition the Trust Clinical Education and Practice Development Teams have been visited wards to support staff in practice with documentation of repositioning, risk assessments and using EPIC effectively.”

    Source location

    Response from Frimley Health NHS Foundation Trust
    Page 3 · response
    Published 16 July 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate the Harm Free Care Audit Programme to test timely assessments and implementation of pressure-injury interventions.

    Verbatim wording from the response

    “A formal Harm Free Care Audit Programme is in place (commenced July 2025). The pressure injury prevention sections test out whether assessments have been done in a timely manner and whether the appropriate care interventions such as repositioning have been put in place. The audit in July 25 showed a 20% improvement in the documentation of the interventions from a previous audit (60% to 80%) compliance.”

    Source location

    Response from Frimley Health NHS Foundation Trust
    Page 3 · response
    Published 16 July 2025

    Open published response

  3. 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.

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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

    Failure to consistently implement repositioning

    Wider context from the report

    “1. Repositioning was undertaken, but recording and implementation was, at times, patchy; ”

    Source location

    Maureen POWELL · Prevention of Future Deaths report
    Page 1 · concerns

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    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

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  4. Somerset

    AI-generated summary

    Cynthia Mary Gilbert · 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

    Cynthia Mary Gilbert, who had cardiac and respiratory illness and reduced mobility, was admitted to hospital after being found unable to stand from the toilet. During her admission, pressure ulcers deteriorated and became infected, and she died from septicaemia on 20 December 2023. Concerns included repeated failures to follow her repositioning care plan despite her very high risk of pressure ulcers, and an unsatisfactory explanation for those failures in the Trust’s post-death investigation.

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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

    Failure to adhere to repositioning care plans for patients at very high risk of pressure ulcer development

    Wider context from the report

    “a) Mrs Gilbert was noted to have grade 2 tissue damage on admission to hospital. She was assessed as being at very high risk of pressure ulcer development. Her care plan included repositioning every 1 to 2 hours. The Intentional Rounding documents show that, during her time spent on the Old Acute Medical Unit and Coleridge Respiratory Unit (1/9/23 to 20/12/23), Mrs Gilbert remained in the same position in bed for periods of many hours on multiple days. b) Evidence given by the tissue viability nurse was that the tissue viability team emphasised the importance of repositioning on five separate occasions to the ward staff. The lack of adherence to the repositioning plan continued despite these communications. c) Mrs Gilbert’s grade 2 tissue damage deteriorated to a grade 4 pressure ulcer during her admission, leading to septicaemia. d) The lack of adherence to the repositioning care plan for a patient at very high risk of developing pressure ulcers raises a concern for future deaths. ”

    Source location

    Cynthia Mary Gilbert · Prevention of Future Deaths report
    Page 2 · concerns

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    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 the Intentional Rounding quality-improvement project and roll out the new tool and training package organisation-wide by June 2025.

    Verbatim wording from the response

    “In response to this, a Quality Improvement (QI) project was commenced in September 2024 with an aim to address these variances and improve the overall understanding, application and staff culture, leading to increased patient safety, a reduction in harm and ultimately better outcomes for patients. Since testing the specific role modelling approach for IR across 5 pilot wards, there has been an improved awareness and understanding from colleagues, a reduced number of reported incidences and / or concerns, with fewer patients suffering harm through the adverse effects of pressures leading to pressure damage. A new tool was developed which will capture more accurately the care delivery”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 1 · response
    Published 4 February 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain mandatory pressure-ulcer-prevention eLearning and associated aSSKINg-based education, including Waterlow assessment resources and eAssessment tools.

    Verbatim wording from the response

    “• Introduction of a mandatory eLearning module for Pressure Ulcer Prevention – which notes the importance of repositioning patients and highlights immobility as a key risk factor for developing pressure ulcers. Most recent figures demonstrate 93% compliance with substantive staff mapped to the training.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 2 · response
    Published 4 February 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use education, audits and further ward-based quality-improvement projects to improve pressure-ulcer prevention and management.

    Verbatim wording from the response

    “• Education project 2023-24 – which saw 1251 education contacts, pre (1161) and post (481) knowledge questionnaires and audits that saw approximately 500 patient records reviewed within inpatient settings across the project. Further QI projects (with 6 ward areas with higher pressure ulcer rates) were commenced on the back of the results.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 2 · response
    Published 4 February 2025

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    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 align inpatient care-plan templates and documents using the aSSKINg framework.

    Verbatim wording from the response

    “• Review and alignment of care plan templates/documents across the inpatient settings, which will incorporate the aSSKINg framework as a basis.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 2 · response
    Published 4 February 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review lateral-turning devices, assess available options and risks, and develop a standard operating procedure to support equitable access and safe repositioning.

    Verbatim wording from the response

    “• There is work, as a national safety alert (cot sides and bed accessories), to review the use of lateral turning devices (integral to mattress or separate support device to aid lateral turning/repositioning). This will include what devices are available to ensure equity of access, risk assessment tools for their use and developing a Standard Operational Procedure (SOP) document.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 3 · response
    Published 4 February 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Have matrons work clinically on wards weekly to support training, identify high-risk patients, and lead ward rounds and safety huddles.

    Verbatim wording from the response

    “The ADPC is carrying out patient and relative engagement walk rounds across all of our wards, during visiting hours, this have been very positive and allows us to hear about areas of notable good practice and areas of concerns that need to be addressed. A plan has been put in place to carry out a 15 steps challenge on several wards across the trust. Night walk rounds are ongoing by the ADPC across both acute sites and have been well received by both staff and the wider MDT. The matrons are now working 20% clinical on our wards weekly supporting with training and education and supporting with the identification of our high-risk patients and are leading on ward rounds and safety huddles with the ward senior leadership team.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 3 · response
    Published 4 February 2025

    Open published response

  5. Devon, Plymouth and Torbay

    AI-generated summary

    Raymond Albert Alfred Reid · 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

    Raymond Albert Alfred Reid was admitted to hospital with a catheter-related urinary tract infection, developed pressure sores and pneumonia during a prolonged stay, and died on 1 March 2023. The report identified concerns about gaps in pressure sore prevention, monitoring, documentation, nutritional screening, repositioning, wound follow-up and photography.

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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

    Delays in moving patients to prevent pressure sore deterioration

    Wider context from the report

    “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that: a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy. b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy. c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded. d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy. e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice. f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression. g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood. ”

    Source location

    Raymond Albert Alfred Reid · Prevention of Future Deaths report
    Page 2 · concerns

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    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 reported tissue-damage incidents, take immediate local learning actions, and assess implications for the Trust-wide improvement plan.

    Verbatim wording from the response

    “From this, you can see that there is a huge amount of work covered by the Group. All Care Groups attend the quarterly meeting and it is jointly led by the two Trust Tissue Viability Leads. All reported incidents of tissue damage are reviewed by the TV team in collaboration with the Care Group Senior Nurses. Immediate local learning/actions will be taken following this initial review. All incidents will also be reviewed to determine any implications for the Trust wide TV improvement plan. Trends and discrepancies in care can be identified centrally and early work can then be done to improve patient care.”

    Source location

    Response from Royal Devon Healthcare NHS
    Page 2 · response
    Published 11 March 2025

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    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 Northern-site leadership workstream to strengthen front-line nursing practice in pressure-ulcer prevention and management, with senior oversight of delivery.

    Verbatim wording from the response

    “In order to ensure that this is actually being delivered on the front line, the Chief Nursing Officer has commissioned a significant leadership piece of work from the Director of Nursing on the Northern site. She has been asked to ensure we have right systems and processes for care in Northern services and specifically looking to “foster leadership in best practice in front line nursing staff who have ward based responsibilities regarding the day to day prevention and management of pressure ulcers”. This Group is being set up and delivery against the agreed actions will be report to the Tissue Viability Group and the Patient Safety Committee so again there will be high level and senior oversight of this piece of work.”

    Source location

    Response from Royal Devon Healthcare NHS
    Page 2 · response
    Published 11 March 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing Trust-wide pressure damage prevention arrangements provide sufficient assurance that further work and dissemination are not required.

    Verbatim wording from the response

    “I am pleased to be able to write and provide you with real assurance that the Trust is doing significant work to reduce pressure damage in patients and I hope you will be reassured that this has been a priority of the Trust for some time now and substantial work is being done to ensure improvements.”

    Source location

    Response from Royal Devon Healthcare NHS
    Page 1 · response
    Published 11 March 2025

    Open published response

  6. Birmingham and Solihull

    AI-generated summary

    Phyllis TROMANS · 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

    Phyllis Tromans, a long-term resident with Parkinson’s disease who was in a frail condition, developed a grade 4 pressure ulcer while an inpatient at Queen Elizabeth Hospital and died at Cotteridge House on 24 May 2024. Concerns included an underestimated pressure sore risk assessment, prolonged periods without repositioning, an incomplete wound care plan, and an investigation that did not establish why gaps in care had occurred.

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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

    Failure to adhere to scheduled repositioning intervals

    Wider context from the report

    “2. Mrs Tromans had a repositioning schedule in place when she was admitted to the Acute Medical Unit and subsequently to ward East Ground B. This required repositioning at no greater intervals of four hours to mitigate the risk of pressure sores. On a total of 22 occasions the schedule was not adhered to. This led to occasions where Mrs Tromans was left in the same position for up to 14 hours. ”

    Source location

    Phyllis TROMANS · 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

    Deliver repositioning training for Tissue Viability Link Workers with therapy-team pressure mapping and safe side-lying education.

    Verbatim wording from the response

    “• Training: In December, two Tissue Viability Link Worker events focused on repositioning were held, with support from therapy teams using pressure mapping devices to identify pressure points and promote effective repositioning. The sessions also provided education on anatomy and physiology, with an emphasis on safe side-lying techniques to relieve pressure.”

    Source location

    Response from University Hospitals Birmingham
    Page 2 · response
    Published 1 November 2024

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    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 Acute Medical Unit repositioning audits, provide real-time feedback and reinforce schedule compliance through staff communications.

    Verbatim wording from the response

    “• Compliance Monitoring: A weekly audit of repositioning practices in the AMU is now being conducted, with real-time feedback provided to staff. The AMU also receives regular communications emphasizing the importance of following the repositioning schedule and completing daily care plans.”

    Source location

    Response from University Hospitals Birmingham
    Page 2 · response
    Published 1 November 2024

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    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 Response Assessment Tool for senior-staff oversight of repositioning strategies and audit its compliance and quality.

    Verbatim wording from the response

    “• Response Assessment Tool (RAT): The Tissue Viability team has implemented the RAT to scope trust-acquired pressure ulcer events. This tool, which will be used by senior staff to ensure repositioning strategies are being followed, will be audited for compliance and quality.”

    Source location

    Response from University Hospitals Birmingham
    Page 2 · response
    Published 1 November 2024

    Open published response

  7. East Sussex

    AI-generated summary

    Carol Ann DIVALL · 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 Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.

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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

    Failure to provide two-hourly repositioning

    Wider context from the report

    “C. Mrs Divall developed a grade 4 sacral pressure sore. She was not referred to the Tissue Viability Nurse until 1.10.22 who confirmed in her evidence that it would have taken 12-14 days to develop and would therefore have been available to be seen by the nursing staff caring for her. Contributing to the deterioration of her pressure sore was the deflating of her hybrid mattress on at least 2 occasions. Mr Divall noticed who visited for long periods every day noticed that his wife was never repositioned as she should have been on a 2 hourly basis at any time during his daily visits. I consider that Mrs Divall's immobility and malnourishment contributed to the development of her pressure sore the care of and severity were not mentioned in the discharge summary. ”

    Source location

    Carol Ann DIVALL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. 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.

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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

    Failure to provide structured repositioning and offloading of pressure areas

    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 4 · 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

  9. Nottinghamshire

    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 regularly document repositioning

    Wider context from the report

    “2. The lack of regular documented repositioning of Norma, with no understanding by the management team as to how and why this issue had occurred. ”

    Source location

    Norma Lockton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Surrey

    AI-generated summary

    Mr Charles Knapp · 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 Charles Knapp, who was paraplegic and dependent on care, developed necrotic pressure sores while living at home and later died in hospital on 24 February 2018 from aspiration pneumonia. The concerns included failures by Angel Solutions (UK) Ltd to maintain his hygiene, reposition him, seek medical attention, provide two carers as required, and maintain or supply complete care records; the Coroner was concerned that inadequate care and records could put other service users at risk of future deaths.

    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 regularly reposition patients

    Wider context from the report

    “(i) Angel Solutions (UK) Ltd omitted to maintain Mr Knapp’s personal hygiene or regularly reposition him, and thereafter omitted to seek medical attention for the pressure sores. These omissions contributed to the development of the pressure sores and to Mr Knapp’s death. ”

    Source location

    Mr Charles Knapp · Prevention of Future Deaths report
    Page 3 · 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