PFD report

Myra Maxfield · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 25 Oct 2023•Staffordshire and Stoke-on-Trent

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Unavailability of Tissue Viability Team over weekends causing delays in patient assessment
    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.1

  1. Action

    Monitor Specialist Tissue Viability Team referral-to-response times according to pressure-ulcer severity.

    Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 October 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The relevant NHS Trust is responsible for commenting on tissue viability provision at Royal Stoke University Hospital.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Unavailability of Tissue Viability Team over weekends causing delays in patient assessment

Wider context from the report

“1. Evidence emerged during the inquest that it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours. 2. It was said that, delays in doing so, could be causative in the death of patients. 3. Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend, and this leads to substantial delay in patients being seen. ”

Is this part of a recurring concern?

Yes — Insufficient tissue viability service capacity and access.

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

Monitor Specialist Tissue Viability Team referral-to-response times according to pressure-ulcer severity.

Verbatim wording from the response

“In response to your concerns, we will continue to monitor the timeliness of pressure ulcer risk assessment completion by our Ward/Department teams via our monthly Tendable Care Excellence audits. We will also ensure that the referral criteria for Ward/Department Teams to refer patients to the Tissue Viability Team for specialist advice and support is reviewed and included in UHNМ Trust Policy C63, Prevention and Management of Pressure Ulcers. We will subsequently monitor referral to response times, according to the severity of the Pressure Ulcer, by our Specialist Tissue Viability Team.”

Source location

Response from University Hospitals of North Midlands
Page 3 · response
Published 31 October 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

The relevant NHS Trust is responsible for commenting on tissue viability provision at Royal Stoke University Hospital.

Verbatim wording from the response

“NHS England is not able to provide comment on the provision of the service specifically within Royal Stoke University Hospital and would refer you to the Trust on this issue.”

Source location

Response from NHS England
Page 2 · response
Published 31 October 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

NICE or the National Wound Care Strategy Programme should be engaged because no specific guidance sets tissue viability referral timings.

Verbatim wording from the response

“There are no specific guidelines for when patients should be referred to a Tissue Viability Specialist (TVS) within the NICE guidance or in the international best practice guidelines. You may wish to engage with NICE or the NWCSP regarding this issue.”

Source location

Response from NHS England
Page 2 · response
Published 31 October 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

Routine weekend Tissue Viability coverage is unnecessary because pathways, policies, guidance and staff training mitigate pressure-ulcer risks out of hours.

Verbatim wording from the response

“We strive to provide a high standard of care to all of our patients and preventing avoidable pressure ulcers and managing existing pressure ulcers, as in the case of Mrs Maxfield, is an important quality metric. People in hospital can be at higher risk of pressure ulcer damage but we have a range of support for teams to minimise the risk of pressure ulcer development or deterioration. UHNМ provide a regular 5-Day (Monday – Friday) Tissue Viability Service, which is in line with most acute Trusts nationally. However, as demonstrated in the case of Mrs Maxwell, a limited service is provided at weekends in extenuating circumstances and on an ad hoc basis.”

Source location

Response from University Hospitals of North Midlands
Page 3 · response
Published 31 October 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

The applicable six-hour requirement is for pressure-ulcer risk assessment, not review by the Specialist Tissue Viability Team.

Verbatim wording from the response

“1. As a point of clarification on the issues that you have raised in Point 1 of your letter, regarding the fact that ‘it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours’.”

Source location

Response from University Hospitals of North Midlands
Page 2 · response
Published 31 October 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

    Progress a diagnostic phase of improvement work on pressure-ulcer prevention and management.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2023.
  2. 2

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
  3. 3

    Progress national pressure-ulcer improvement work through the National Patient Safety Strategy.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2023.
  4. 4

    Continue monitoring the timeliness of pressure-ulcer risk assessments through monthly Tendable Care Excellence audits.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2023.
  5. 5

    Review referral criteria for specialist Tissue Viability advice and include them in Trust Policy C63.

    Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 October 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    For severe infection, prompt medical-team review is expected, and urgent tissue viability review would likely result in the same referral.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    A delay in completing the initial pressure-ulcer risk assessment is not necessarily causative of death because outcome depends on subsequent care.

    Stated by University Hospitals of North Midlands NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 a diagnostic phase of improvement work on pressure-ulcer prevention and management.

Verbatim wording from the response

“I would like to assure you that further work has been progressed nationally to further improve pressure ulcer care and reduce the risk of harm to patients. In addition to the NWCSP, further work is also underway as part of the National Patient Safety Strategy and further work is underway to progress a diagnostic phase of improvement work in relation to pressure ulcer prevention and management.”

Source location

Response from NHS England
Page 2 · response
Published 31 October 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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 3 · response
Published 31 October 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 national pressure-ulcer improvement work through the National Patient Safety Strategy.

Verbatim wording from the response

“I would like to assure you that further work has been progressed nationally to further improve pressure ulcer care and reduce the risk of harm to patients. In addition to the NWCSP, further work is also underway as part of the National Patient Safety Strategy and further work is underway to progress a diagnostic phase of improvement work in relation to pressure ulcer prevention and management.”

Source location

Response from NHS England
Page 2 · response
Published 31 October 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

Continue monitoring the timeliness of pressure-ulcer risk assessments through monthly Tendable Care Excellence audits.

Verbatim wording from the response

“In response to your concerns, we will continue to monitor the timeliness of pressure ulcer risk assessment completion by our Ward/Department teams via our monthly Tendable Care Excellence audits. We will also ensure that the referral criteria for Ward/Department Teams to refer patients to the Tissue Viability Team for specialist advice and support is reviewed and included in UHNМ Trust Policy C63, Prevention and Management of Pressure Ulcers. We will subsequently monitor referral to response times, according to the severity of the Pressure Ulcer, by our Specialist Tissue Viability Team.”

Source location

Response from University Hospitals of North Midlands
Page 3 · response
Published 31 October 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 referral criteria for specialist Tissue Viability advice and include them in Trust Policy C63.

Verbatim wording from the response

“Referral criteria for Ward/Department Teams to refer patients to the Tissue Viability Team for specialist advice and support is available on the UHNМ Trust Intranet pages.”

Source location

Response from University Hospitals of North Midlands
Page 2 · response
Published 31 October 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

For severe infection, prompt medical-team review is expected, and urgent tissue viability review would likely result in the same referral.

Verbatim wording from the response

“In the case of a patient showing signs of a severe infection that could potentially lead to death, it is expected that the patient would be promptly referred to the medical team for urgent review, treatment and appropriate intervention and management.”

Source location

Response from NHS England
Page 2 · response
Published 31 October 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

A delay in completing the initial pressure-ulcer risk assessment is not necessarily causative of death because outcome depends on subsequent care.

Verbatim wording from the response

“2. Delays may be causative in the death of patients.”

Source location

Response from University Hospitals of North Midlands
Page 2 · response
Published 31 October 2023

Open published response
Back to top

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