PFD report

Jean Marjorie McHALE · Prevention of Future Deaths report

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Issued 15 Dec 2016•Bedfordshire and Luton

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

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 raised2

  1. Failure to appropriately treat pressure ulcers in elderly people in the community
    Part of recurring concern: Inadequate management of pressure ulcers
  2. Insufficient Tissue Viability Nurse staffing in community and hospital settings
    Part of recurring concern: Insufficient tissue viability service capacity and access
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.5

  1. Action

    Complete a review of the community tissue viability nursing service.

    Stated by TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2017.
  2. Action

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

    Stated by TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2017.
  3. Action

    Investigate all category 3 and 4 pressure ulcers through root-cause analysis and Skin Matters panels to identify learning.

    Stated by TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2017.

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 appropriately treat pressure ulcers in elderly people in the community

Wider context from the report

“(1) That if pressure ulcers are not treated appropriately to the elderly in the community will suffer, develop Osteomyelitis leading to Sepsis and death. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient Tissue Viability Nurse staffing in community and hospital settings

Wider context from the report

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

Is this part of a recurring concern?

Yes — Insufficient tissue viability service capacity and access.

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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 a review of the community tissue viability nursing service.

Verbatim wording from the response

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

Source location

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

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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

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

Verbatim wording from the response

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

Source location

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

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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

Investigate all category 3 and 4 pressure ulcers through root-cause analysis and Skin Matters panels to identify learning.

Verbatim wording from the response

“All category 3 and 4 pressure ulcers acquired in our care are thoroughly investigated through root cause analysis and ‘Skin Matters’ panels to review care given and identify if any learning can be taken forward.”

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Increase the provision of community tissue viability nurses.

Verbatim wording from the response

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

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Maintain clear referral pathways for timely access to tissue viability nursing services.

Verbatim wording from the response

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

Source location

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

Open published response

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.2

  1. 1

    Provide ongoing pressure-ulcer prevention and early-detection training and monitoring for community nurses.

    Stated by TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017.
  2. 2

    Work with health and local-authority partners to support pressure-ulcer pathways, training and awareness.

    Stated by TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2017.

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 ongoing pressure-ulcer prevention and early-detection training and monitoring for community nurses.

Verbatim wording from the response

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

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Work with health and local-authority partners to support pressure-ulcer pathways, training and awareness.

Verbatim wording from the response

“The Trust remains committed to continue to take action to reduce the number of pressure ulcers in the community and we have worked with the CCG, local authority and acute hospitals to support pathways, training and raising awareness.”

Source location

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

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