PFD report

Mildred Joan Griffiths · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 17 Nov 2017•Birmingham and Solihull

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised2

  1. Use of pressure sore risk tools with opposing score interpretations
    Part of recurring concern: Inadequate management of pressure ulcersPart of recurring concern: Unreliable objective criteria for safety risk assessment
  2. Failure of the pressure sore risk tool to account for existing lesions
    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.1

  1. Action

    Keep use of the Braden tool under ongoing review against national guidance and standards.

    Stated by Avery Healthcare GroupStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The wound would likely have deteriorated regardless of the pressure-ulcer risk assessment tool because repositioning was not tolerated and mobility was reduced.

    Stated by Avery Healthcare GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Use of pressure sore risk tools with opposing score interpretations

Wider context from the report

“1. The pressure sore risk tool used in the home is the Braden Score. The community Healthcare Trust use the Walsall score – which is nationally recognised. I note the Braden score does not take into account any existing lesion when calculating the risk which means it may under estimate the risk. In addition the Braden score calculates in an opposite way to the Walsall score – thus a low score is high risk in the Braden score, but low risk in the Walsall score. This can lead to confusion between professionals and the home should consider changing to the Walsall score. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers; Unreliable objective criteria for safety risk assessment.

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 of the pressure sore risk tool to account for existing lesions

Wider context from the report

“1. The pressure sore risk tool used in the home is the Braden Score. The community Healthcare Trust use the Walsall score – which is nationally recognised. I note the Braden score does not take into account any existing lesion when calculating the risk which means it may under estimate the risk. In addition the Braden score calculates in an opposite way to the Walsall score – thus a low score is high risk in the Braden score, but low risk in the Walsall score. This can lead to confusion between professionals and the home should consider changing to the Walsall score. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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

Keep use of the Braden tool under ongoing review against national guidance and standards.

Verbatim wording from the response

“Thus having reviewed your recommendation and the evidence we propose to continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards.”

Source location

2017-0400-Response-by-Avery-Health-Group
Page 2 · response
Published 15 February 2018

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 wound would likely have deteriorated regardless of the pressure-ulcer risk assessment tool because repositioning was not tolerated and mobility was reduced.

Verbatim wording from the response

“The resident who passed away on this occasion was unable to tolerate repositioning, and would frequently reposition herself on to her back, indicating this was where she was most comfortable and would also refuse repositioning. This would have lent itself to deterioration of the wound, regardless of the risk assessment tool being used. The resident moved into the home with a leg plaster cast in situ further decreasing her mobility and making repositioning difficult.”

Source location

2017-0400-Response-by-Avery-Health-Group
Page 2 · response
Published 15 February 2018

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 Braden tool, existing systems and staff training are considered effective, so its use will continue while remaining under ongoing review.

Verbatim wording from the response

“At Avery Healthcare we pride ourselves on the low prevalence of home acquired pressure ulcers within our care homes. We care for over 3000 residents and have an average home acquired prevalence of less than 1.5%. This compares to national rates of between 4.7-32.1% in hospitals and up to 22% in nursing homes (NICE). We use the Braden risk tool to support staff with assessing risk throughout England as it has had studies conducted specifically for the older age group, covers the main areas of risk and has in our experience (and for which there is weak evidence) better inter-rater reliability. The average prevalence rate for home acquired pressure ulcers at St Giles nursing home is 2.3% year to date and there have been several months this year where there have been no home acquired pressure ulcers in the home.”

Source location

2017-0400-Response-by-Avery-Health-Group
Page 2 · response
Published 15 February 2018

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

    Continue using the Braden pressure-ulcer risk assessment tool.

    Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 15 February 2018.
  2. 2

    Conduct a root cause analysis of the case to support organisational learning.

    Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 15 February 2018.

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 using the Braden pressure-ulcer risk assessment tool.

Verbatim wording from the response

“At Avery Healthcare we pride ourselves on the low prevalence of home acquired pressure ulcers within our care homes. We care for over 3000 residents and have an average home acquired prevalence of less than 1.5%. This compares to national rates of between 4.7-32.1% in hospitals and up to 22% in nursing homes (NICE). We use the Braden risk tool to support staff with assessing risk throughout England as it has had studies conducted specifically for the older age group, covers the main areas of risk and has in our experience (and for which there is weak evidence) better inter-rater reliability. The average prevalence rate for home acquired pressure ulcers at St Giles nursing home is 2.3% year to date and there have been several months this year where there have been no home acquired pressure ulcers in the home.”

Source location

2017-0400-Response-by-Avery-Health-Group
Page 2 · response
Published 15 February 2018

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

Conduct a root cause analysis of the case to support organisational learning.

Verbatim wording from the response

“We are confident that the risk tool which we use and the systems and staff training which we have in place are effective but have conducted a root cause analysis in this case to ensure that organisational learning can take place.”

Source location

2017-0400-Response-by-Avery-Health-Group
Page 2 · response
Published 15 February 2018

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