PFD report

George Edward GRIFFITHS · Prevention of Future Deaths report

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Issued 28 Jun 2023•Herefordshire

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
16

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 raised5

  1. Failure to remove footwear for foot inspection
    Part of recurring concern: Failure to perform clinically indicated physical examinations
  2. Failure to appropriately manage or refer necrotic toes
  3. Delays in reassessment and implementation of pressure relieving measures
    Part of recurring concern: Inadequate management of pressure ulcers
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.11

  1. Action

    Hold weekly multidisciplinary Pressure Ulcer panels and use rapid reviews to identify omissions, rectify care and capture learning.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  2. Action

    Develop an automated dashboard showing assessment and care-plan status to nurses in charge.

    Stated by Wye Valley NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
  3. Action

    Provide new pressure-relieving mattress toppers on all Emergency Department trolleys.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.

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

  1. Position

    Mandatory pressure area care training is not considered necessary because relevant education is included in existing staff training and induction arrangements.

    Stated by Wye Valley NHS 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

Failure to remove footwear for foot inspection

Wider context from the report

“(1) The patient appears to have been held in ED for 40+ hours during which time footwear was not removed. Necrotic Toe apparent without evidence of appropriate management or referral. ”

Is this part of a recurring concern?

Yes — Failure to perform clinically indicated physical examinations.

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 appropriately manage or refer necrotic toes

Wider context from the report

“(1) The patient appears to have been held in ED for 40+ hours during which time footwear was not removed. Necrotic Toe apparent without evidence of appropriate management or referral. ”

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

Delays in reassessment and implementation of pressure relieving measures

Wider context from the report

“(2) Skin inspection on admission confirmed that all areas were intact but there is no evidence of preventative care despite patients’ time on ED (40 hours) and in AMU (5 days). Acknowledgement of pressure area damage occurred on the 8th February but no reassessment took place until the 20th February with consequent failure to implement pressure relieving measures. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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

Lack of preventative pressure area care

Wider context from the report

“(2) Skin inspection on admission confirmed that all areas were intact but there is no evidence of preventative care despite patients’ time on ED (40 hours) and in AMU (5 days). Acknowledgement of pressure area damage occurred on the 8th February but no reassessment took place until the 20th February with consequent failure to implement pressure relieving measures. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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 mandate pressure area care training

Wider context from the report

“(3) The Pressure Sore acquired in Hospital contributed to the death and it is noted that pressure area care training is not mandatory within Wye Valley Trust. ”

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

Hold weekly multidisciplinary Pressure Ulcer panels and use rapid reviews to identify omissions, rectify care and capture learning.

Verbatim wording from the response

“The Trust also holds a weekly Pressure Ulcer panel with subject matter experts (Tissue Viability/ Safeguarding/ Quality & Safety/ Therapies/ Matrons) where all incidences of pressure damage are discussed. Ward managers are invited to complete rapid reviews so that any omissions of care can be identified and rectified and to ensure learning takes place.”

Source location

Response from Wye Valley NHS Trust
Page 3 · response
Published 7 July 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

Develop an automated dashboard showing assessment and care-plan status to nurses in charge.

Verbatim wording from the response

“Having moved from a paper assessment and care planning system onto a digital platform we have recognised that senior nursing oversight (nurse in charge) of the status of all patient assessments is not as accessible and obvious as when documentation was kept at the end of the patients’ bed. Part of our improvement plan is to develop an automated dashboard on the digital system, which will enable the nurse in charge to check the status of assessments and care plans for all patients in their charge. In addition, the assessment document itself is being reviewed to simplify the steps for completion and to add in prompts for accessing equipment/referring for specialist advice etc.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Provide new pressure-relieving mattress toppers on all Emergency Department trolleys.

Verbatim wording from the response

“The ED department has recently invested in new mattress toppers for all ED trolleys to mitigate the risk of patients developing pressure damage in the event a patient has a longer than expected wait in the department and for those patients most at risk a bed and air mattress can be requested.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Update the Trust pressure-area-care policy to cover Emergency Department care.

Verbatim wording from the response

“A thematic review of pressure damage cases in ED has also identified further areas for improvement that will be formalised into a departmental improvement plan. This includes a review of our Trust policy, which currently focusses on pressure area care in inpatient areas. The policy is being updated and an”

Source location

Response from Wye Valley NHS Trust
Page 1 · response
Published 7 July 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

Add an Emergency Department standard operating procedure for timely, systematic pressure-area care.

Verbatim wording from the response

“A thematic review of pressure damage cases in ED has also identified further areas for improvement that will be formalised into a departmental improvement plan. This includes a review of our Trust policy, which currently focusses on pressure area care in inpatient areas. The policy is being updated and an”

Source location

Response from Wye Valley NHS Trust
Page 1 · response
Published 7 July 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

Modify the equipment-library request process so pressure-relieving mattresses and chair cushions are routinely supplied together.

Verbatim wording from the response

“Early identification of the need for pressure relieving equipment is crucial to support better pressure area care. The Trust has modified the request process from the equipment library so that pressure relieving mattresses and chair cushions are provided routinely as part of the same request.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Review and simplify the assessment document, adding prompts for equipment and specialist referrals.

Verbatim wording from the response

“Having moved from a paper assessment and care planning system onto a digital platform we have recognised that senior nursing oversight (nurse in charge) of the status of all patient assessments is not as accessible and obvious as when documentation was kept at the end of the patients’ bed. Part of our improvement plan is to develop an automated dashboard on the digital system, which will enable the nurse in charge to check the status of assessments and care plans for all patients in their charge. In addition, the assessment document itself is being reviewed to simplify the steps for completion and to add in prompts for accessing equipment/referring for specialist advice etc.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Develop and pilot a local pressure-area-care competency package in high-risk clinical areas.

Verbatim wording from the response

“In addition to core training, e-learning modules are available for all staff to refresh their skills and knowledge. A local competency package has been developed and has been piloted in areas where patients are most at risk (Frailty service). Once this has been evaluated, the competency programme will be rolled out more widely in the Medical Division, which will include the Emergency Department and Acute Medical Unit.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Refresh Tissue Viability link-nurse roles and provide additional training to their role holders.

Verbatim wording from the response

“The Trust has Tissue Viability link nurse roles across the wards and relevant departments. This role has been refreshed as part of our overarching improvement plan and the individuals have received additional training. These members of staff are ‘on the ground’ experts and can provide timely advice and make recommendations for treatment plans. In addition, the Tissue Viability team are there to provide specialist advice if the ward based team feel specialist input is required and referral is necessary.”

Source location

Response from Wye Valley NHS Trust
Page 3 · response
Published 7 July 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

Introduce senior nurse care reviews for patients spending extended periods in the Emergency Department.

Verbatim wording from the response

“The ED has since recognised the need to implement new ways of working in response to the sustained pressures and patients spending far longer in the department than we would like. In response, we introduced a senior nurse care review, to meet the needs of those patients spending a long time in ED waiting for a bed. The care review is akin to the review ward based nurses would undertake and is intended to ensure that comprehensive care assessments and planning that would not ordinarily happen in an Emergency Department are undertaken.”

Source location

Response from Wye Valley NHS Trust
Page 1 · response
Published 7 July 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

Roll out the competency programme across the Medical Division, including Emergency Department and Acute Medical Unit areas, after evaluation.

Verbatim wording from the response

“In addition to core training, e-learning modules are available for all staff to refresh their skills and knowledge. A local competency package has been developed and has been piloted in areas where patients are most at risk (Frailty service). Once this has been evaluated, the competency programme will be rolled out more widely in the Medical Division, which will include the Emergency Department and Acute Medical Unit.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Mandatory pressure area care training is not considered necessary because relevant education is included in existing staff training and induction arrangements.

Verbatim wording from the response

“Whilst pressure area care training is not mandatory at the Trust, front line nurses and nursing associates do receive pressure area prevention, assessment and care planning education as part of their core pre-registration training and for health care support staff this is taught as part of their care certificate and clinical skills training or induction to the organisation. Given the Trusts improvement plan and desire to improve clinical practice the Chief Nursing Officer has also contacted the local university to check that the pre-registration curriculum remains fit for purpose in this regard.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 2023

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.5

  1. 1

    Prioritise the national CQUIN for pressure-area assessment within the Trust’s annual contract.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  2. 2

    Progress the urgent and emergency care transformation programme to improve Emergency Department flow, pathways and bed capacity.

    Stated by Wye Valley NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
  3. 3

    Audit assessment and care-plan completion quality and report results through quality and performance forums.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  4. 4

    Check with the local university that the pre-registration curriculum remains fit for purpose for pressure-area care.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  5. 5

    Formalise identified Emergency Department pressure-care improvements into a departmental improvement plan.

    Stated by Wye Valley NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.

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

Prioritise the national CQUIN for pressure-area assessment within the Trust’s annual contract.

Verbatim wording from the response

“Regular audit of the quality of completion of assessments and care plans is undertaken and monitored by the matrons for all wards including AMU. The results of these audits are reported through our quality and performance monitoring forums. The Trust has included the national CQUIN for pressure area assessment as a priority into this year’s contract and this forms part of our overall approach to improving practice in this area.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Progress the urgent and emergency care transformation programme to improve Emergency Department flow, pathways and bed capacity.

Verbatim wording from the response

“Given the pressures across Emergency Departments in the NHS, we are also focussing on an urgent and emergency care transformation programme, which aims to reduce congestion in ED, improve patient flow and pathways and ensure sufficient bed capacity.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Audit assessment and care-plan completion quality and report results through quality and performance forums.

Verbatim wording from the response

“Regular audit of the quality of completion of assessments and care plans is undertaken and monitored by the matrons for all wards including AMU. The results of these audits are reported through our quality and performance monitoring forums. The Trust has included the national CQUIN for pressure area assessment as a priority into this year’s contract and this forms part of our overall approach to improving practice in this area.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Check with the local university that the pre-registration curriculum remains fit for purpose for pressure-area care.

Verbatim wording from the response

“Whilst pressure area care training is not mandatory at the Trust, front line nurses and nursing associates do receive pressure area prevention, assessment and care planning education as part of their core pre-registration training and for health care support staff this is taught as part of their care certificate and clinical skills training or induction to the organisation. Given the Trusts improvement plan and desire to improve clinical practice the Chief Nursing Officer has also contacted the local university to check that the pre-registration curriculum remains fit for purpose in this regard.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 7 July 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

Formalise identified Emergency Department pressure-care improvements into a departmental improvement plan.

Verbatim wording from the response

“A thematic review of pressure damage cases in ED has also identified further areas for improvement that will be formalised into a departmental improvement plan. This includes a review of our Trust policy, which currently focusses on pressure area care in inpatient areas. The policy is being updated and an”

Source location

Response from Wye Valley NHS Trust
Page 1 · response
Published 7 July 2023

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