PFD report

Raymond Albert Alfred Reid · Prevention of Future Deaths report

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Issued 28 Nov 2024•Devon, Plymouth and Torbay

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Delays in moving patients to prevent pressure sore deterioration
    Part of recurring concern: Failure to reliably reposition patients at required intervalsPart of recurring concern: Inadequate management of pressure ulcersPart of recurring concern: Inadequate wound management for deteriorating wounds
  2. Failure to complete malnutrition universal screening tool assessments
    Part of recurring concern: Inadequate management of malnutrition risk
  3. Failure to complete and repeat pressure ulcer risk assessments
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

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

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2025.
  2. Action

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

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

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

    Stated by Royal Devon University Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure to reliably reposition patients at required intervals; Inadequate management of pressure ulcers; Inadequate wound management for deteriorating wounds.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete malnutrition universal screening tool assessments

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. ”

Is this part of a recurring concern?

Yes — Inadequate management of malnutrition risk.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete and repeat pressure ulcer risk assessments

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to photograph wounds to monitor progression or 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. ”

Is this part of a recurring concern?

Yes — Inadequate wound management for deteriorating wounds.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to plan follow-up after Tissue Viability Team assessment

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to routinely document skin checks

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. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete an initial skin check within 6 hours of admission

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review 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

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

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

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Maintain pressure-damage prevention as a top priority within the Trust-wide Improvement Plan, with regular review and executive oversight.

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2025.
  2. 2

    Implement and oversee the Tissue Viability Improvement Work Plan, updating it quarterly with accountable improvement actions.

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2025.
  3. 3

    Operate a Trust-wide Tissue Viability Steering Group to coordinate pressure-damage improvement across both sites.

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2025.

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 pressure-damage prevention as a top priority within the Trust-wide Improvement Plan, with regular review and executive oversight.

Verbatim wording from the response

“The Trust has an annually refreshed plan (the Trust-wide Improvement Plan) which is informed by scrutiny of events over the preceding year. This enables us to target our efforts on key areas of work that require ongoing quality improvement. The prevention of pressure damage has been recognised as one of these areas and continues to be one of our five main priority areas as per our Improvement plan. This issue has been on the Plan for some time, and this was refreshed in December 2024 and it remained on the plan as a top priority.”

Source location

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

Implement and oversee the Tissue Viability Improvement Work Plan, updating it quarterly with accountable improvement actions.

Verbatim wording from the response

“I am also attaching the Tissue Viability Improvement Work Plan 2024-2025. This Plan is developed, implemented and overseen by the Tissue Steering Group and is updated on a quarterly basis at the meeting. It is a comprehensive work plan setting out specific actions for improvement with accountability for completion.”

Source location

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

Operate a Trust-wide Tissue Viability Steering Group to coordinate pressure-damage improvement across both sites.

Verbatim wording from the response

“Tissue Viability Steering Group”

Source location

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

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026