7 Mar 2022 Michael John Humphries · Prevention of Future Deaths report Surrey
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Concerns raised 5 Inadequate wound care knowledge View source Lack of information on proper use of Tbar cushions View source Failure to maintain accurate wound tracking documentation View source Failure of the TVN referral and initial telephone consultation process to identify wound care issues View source Unavailability of correct dressings to non-TVN professionals View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Michael John Humphries · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael John Humphries, who was quadriplegic and diabetic, was admitted to hospital on 20 March 2019 with severe sepsis and died on 30 March 2019 after being placed into palliative care. Concerns included the lack of information about the proper use of a Tbar cushion, inadequate wound-care knowledge and documentation, limited access to suitable dressings, and an ineffective initial referral process to tissue viability nurses.
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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. The report was sent to Surrey Downs Tissue Viability and Lymphoedema Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate wound care knowledge
Wider context from the report “1. Tbar cushion arrived with Michael without any information on its proper use.
2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound.
3. Wound care knowledge was not adequate.
4. Provision of correct dressings not available to non-TVN professionals.
5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care.
6. Information may be useful to National Wound Care Strategy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey Downs Tissue Viability and Lymphoedema Service; that does not assign responsibility.
PFD Monitor interpretation Lack of information on proper use of Tbar cushions
Wider context from the report “1. Tbar cushion arrived with Michael without any information on its proper use.
2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound.
3. Wound care knowledge was not adequate.
4. Provision of correct dressings not available to non-TVN professionals.
5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care.
6. Information may be useful to National Wound Care Strategy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey Downs Tissue Viability and Lymphoedema Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate wound tracking documentation
Wider context from the report “1. Tbar cushion arrived with Michael without any information on its proper use.
2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded . This has made it more difficult to chart the progress of this wound .
3. Wound care knowledge was not adequate.
4. Provision of correct dressings not available to non-TVN professionals.
5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care.
6. Information may be useful to National Wound Care Strategy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey Downs Tissue Viability and Lymphoedema Service; that does not assign responsibility.
PFD Monitor interpretation Failure of the TVN referral and initial telephone consultation process to identify wound care issues
Wider context from the report “1. Tbar cushion arrived with Michael without any information on its proper use.
2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound.
3. Wound care knowledge was not adequate.
4. Provision of correct dressings not available to non-TVN professionals.
5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care.
6. Information may be useful to National Wound Care Strategy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey Downs Tissue Viability and Lymphoedema Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of correct dressings to non-TVN professionals
Wider context from the report “1. Tbar cushion arrived with Michael without any information on its proper use.
2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound.
3. Wound care knowledge was not adequate.
4. Provision of correct dressings not available to non-TVN professionals.
5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care.
6. Information may be useful to National Wound Care Strategy.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations