PFD report

David Joseph DUGDALE · Prevention of Future Deaths report

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Issued 8 Jan 2026•East Sussex

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.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
24

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 raised3

  1. Poor management of pain
    Part of recurring concern: Failure to provide timely and adequate pain relief
  2. Failure to provide adequate pressure sore care
    Part of recurring concern: Inadequate management of pressure ulcers
  3. Insufficient nutritional support for inpatients
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needs
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.16

  1. Action

    Continue Trust-wide pressure-ulcer prevention work through category monitoring, monthly audits, CQUIN compliance oversight, and Pressure Ulcer Steering Group governance.

    Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
  2. Action

    Implement an expedited fractured-hip and long-bone pain pathway, including prompt orthopaedic review, appropriate analgesia or nerve block, and a completed transfer pain checklist.

    Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2026.
  3. Action

    Circulate a Safety Pin to share pain-management learning and reinforce expectations across divisions.

    Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.

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

Poor management of pain

Wider context from the report

“1. Poor management of David's pain. In spite of sustaining a category 2 pressure sore and bilateral hip fractures whilst in patient at EDGH, he was only receiving oral paracetamol. Not until ambulance crew raised their concerns about his inadequate pain relief prior to their transferring him to Conquest Hospital did he receive increased and more appropriate pain relief. His carers repeatedly tried to advise nursing staff that he was in pain, but their concerns were not listened to nor acted upon. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate pain relief.

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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

Failure to provide adequate pressure sore care

Wider context from the report

“3. The pressure sore deteriorated to grade 4 during his admission which was a direct cause of his death. He was often found lying in soiled dressings with his pressure sore exposed and in pain by his visiting carers. ”

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

Insufficient nutritional support for inpatients

Wider context from the report

“2. David lost 3kgs in weight during the first month of his admission to EDGH. He was not eating nor drinking. There seemed to be little nutritional support available to David in the early stages of his admission causing him to lose almost 30kgs in total. ”

Is this part of a recurring concern?

Yes — Inadequate management of patients' nutrition and hydration needs.

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

Continue Trust-wide pressure-ulcer prevention work through category monitoring, monthly audits, CQUIN compliance oversight, and Pressure Ulcer Steering Group governance.

Verbatim wording from the response

“Alongside the above, the PUSG plans several educational and promotional events for staff and patients during national ‘Stop the Pressure Week’ in November. These events rotate between hospital sites and community locations to encourage a range of attendees from all settings. The programme of events for these days is planned and coordinated by the tissue viability team and are designed to meet the most recent priorities or areas for improvement identified by learning from incidents and Inquests (attachments F&G). A programme of work/activity is developed annually by the Trust Pressure Ulcer Steering Group (PUSG) to reduce risk of pressure damage based on learning from previous incidents, Inquests, audit findings and national guidance and recommendations.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 5 · response
Published 9 January 2026

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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

Implement an expedited fractured-hip and long-bone pain pathway, including prompt orthopaedic review, appropriate analgesia or nerve block, and a completed transfer pain checklist.

Verbatim wording from the response

“timely intervention. Care plans are to be adjusted based on the patient's response to analgesia, with clear and concise documentation. Regular communication is maintained between medical teams, nursing staff, carers, next-of-kin, HCAs, and the Pain Team to ensure optimal pain management. For patients with fractured hip, neck of femur, or long-bone injuries, pain management should be initiated immediately and without delay, including iliopsoas Iliac Nerve Block by trained clinicians in addition to Morphine, Buprenorphine patch, intravenous paracetamol etc. unless contraindicated. Orthopaedic teams will provide prompt review across both sites, and transfers from Eastbourne District General Hospital to Conquest via ambulance will require a completed a neck of femur fracture pain checklist to ensure adequate pain control prior to movement.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 2 · response
Published 9 January 2026

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

Circulate a Safety Pin to share pain-management learning and reinforce expectations across divisions.

Verbatim wording from the response

“Definitive pain management of fractured neck of femur/long bones will be under the Orthopaedic team (surgical management) and a Safety Pin (attachment A) has also been circulated to share learning across divisions and reinforce expectations.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 2 · response
Published 9 January 2026

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 targeted face-to-face pressure-ulcer training, circulate wound-care learning newsletters and webinars, and provide recurring ward study sessions.

Verbatim wording from the response

“The Tissue Viability Nurses regularly provide targeted face to face training in wards and departments where requested. These can be ad hoc in response to incidents or identified knowledge gaps by department leads or on pre-planned routine ward study days with several topics covered, similar to BETU ward. Wards such as Cuckmere ward have received face to face training sessions, with some receiving ongoing 1-hour sessions monthly and pressure ulcer training every 2 months. BETU ward have introduced PFD focused study days in 2025/26 which include 2-hour face to face pressure ulcers sessions. The training being provided also incorporates the Pressure Ulcer Prevention Policy update, dated 15/10/2025 (attachment E), the review of Nevercentre pressure ulcer documentation and the importance of medical photography in supporting pressure ulcer management and surveillance.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 5 · response
Published 9 January 2026

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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

Undertake a formal evaluation of the Trust mandatory training framework during 2026–27 and seek approval for resulting training changes.

Verbatim wording from the response

“As part of the QI project commissioned by the Pressure Ulcer Steering Group (PUSG) on Benson and Egerton Trauma Unit (BETU), additional bitesize face to face training has been piloted on the ward and on bespoke study days. The feedback and evaluation have been positive and reported back to the PUSG with a strong preference for face-to-face learning compared to mandatory eLearning. In turn PUSG requested the NHS Sussex Wound Care Group undertake an evaluation of the mandatory training framework, however the group disbanded in early 2026. As a result, the PUSG is planning to undertake a formal evaluation”

Source location

Response from East Sussex Healthcare NHS Trust
Page 4 · response
Published 9 January 2026

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

Require structured at least-shiftly pain assessments for patients unable to self-report, incorporating learning-disability tools and carer or next-of-kin input.

Verbatim wording from the response

“We recognise that Mr Dugdale did not receive adequate pain relief and recognition of pain in non-verbal, vulnerable, and learning-disabled patients was not of a standard we expect; in response, the following measures are to be implemented immediately. On admission clinical teams are to liaise directly with family members and carers to establish how the patient typically expresses pain and what interventions have previously been effective. “This Is Me” documentation is requested to support the multidisciplinary team in understanding the patient’s individual needs. All patients who are unable to reliably self-report pain receive a structured pain assessment at least once per shift, using the learning disability pain tool and incorporating carer or next-of-kin input, with care-home documentation used where available.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 1 · response
Published 9 January 2026

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

Require admission liaison with carers and use “This Is Me” information to establish how patients express pain and what interventions work.

Verbatim wording from the response

“We recognise that Mr Dugdale did not receive adequate pain relief and recognition of pain in non-verbal, vulnerable, and learning-disabled patients was not of a standard we expect; in response, the following measures are to be implemented immediately. On admission clinical teams are to liaise directly with family members and carers to establish how the patient typically expresses pain and what interventions have previously been effective. “This Is Me” documentation is requested to support the multidisciplinary team in understanding the patient’s individual needs. All patients who are unable to reliably self-report pain receive a structured pain assessment at least once per shift, using the learning disability pain tool and incorporating carer or next-of-kin input, with care-home documentation used where available.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 1 · response
Published 9 January 2026

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

Deliver mandatory and essential wound-care training, including pressure-ulcer prevention, human factors, and simulated patient-safety scenarios for relevant clinical staff.

Verbatim wording from the response

“We also worked in partnership with NHS Sussex and other health care providers in Sussex to agree a mandatory framework for education and training related to wound care for clinical staff including pressure ulcers in line with the National Wound Care Strategy Programme (NWCSP). This includes eLearning and face to face taught elements and different tiers or levels of training are required for staff in different roles (attachment D). The Tissue Viability Nurses also provide face to face training as part of the mandatory induction and preceptorship training for newly qualified or new to Trust nurses. In addition to the mandatory training, the Trust has also introduced essential training days for clinical staff which provides training in human factors and simulated scenarios related to patient safety, for a blended and interactive approach to learning.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 4 · response
Published 9 January 2026

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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

Continue quarterly audits of MUST compliance, referral timeliness, and weight monitoring, with results reported through governance arrangements.

Verbatim wording from the response

“To ensure improvements are maintained and monitored over time, quarterly audits will review MUST compliance, referral timelines, and weight-monitoring practices. LiveFlo monitoring by Matrons and Heads of Nursing will continue to support real-time oversight, and audit results will be reported through the IGM. Immediate reinforcement of these expectations has already taken place, audit results from 2025 are already available and outlined below but we will continue an audit cycle within three to six months.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 2 · response
Published 9 January 2026

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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

Escalate unresolved or carer-reported pain to same-shift senior nursing review and medical assessment, with documented care-plan adjustments and daily pain-checklist review.

Verbatim wording from the response

“Any unresolved pain following simple analgesia, or pain reported by carers, triggers a same-shift senior nurse review and medical escalation. In addition, the Learning Disability Nurse completes and documents a specialist review within 48 hours of admission for all patients with a learning disability.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 1 · response
Published 9 January 2026

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

Jointly plan care with carers and families at admission, document and act on concerns about pain, deterioration, or unmet needs, and improve communication through Trust and Sussex-wide programmes.

Verbatim wording from the response

“The Trust acknowledges the risk associated with failing to respond to repeated concerns raised by carers, and several actions have been implemented to strengthen listening, communication, and escalation culture. On the day of admission, or as close to this as possible, ward staff now jointly plan care with carers and family members to establish an agreed baseline and clarify how changes in the patient’s condition, such as how they express pain, should be communicated. All concerns raised by carers regarding pain,”

Source location

Response from East Sussex Healthcare NHS Trust
Page 5 · response
Published 9 January 2026

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 pain-assessment documentation and escalation monthly, review results through Divisional Governance, and continue ward-round teaching on pain tools and documentation.

Verbatim wording from the response

“To provide assurance of sustained improvement, monthly audits of pain assessment documentation and escalation actions are now in place with the first audit scheduled within three months. Audit outcomes are to be reviewed at Divisional Governance, with escalation for sustained non-compliance. Ongoing teaching of the learning disability pain tool and documentation standards occur during daily medical/surgical ward rounds with priority on using the learning disability pain tool to help in pain assessment/management in cases of learning difficulty, non-verbal and vulnerable patients. We will continue to reinforce the importance of Orthopaedic and Orthogeriatric documentation relating to pain management and checklist.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 2 · response
Published 9 January 2026

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

Run a BETU nutrition-improvement pilot using additional Dietetic staffing, equipment review, and strategies to improve nutrition, then roll learning out across the Trust.

Verbatim wording from the response

“Following these results, a pilot project has recently commenced on BETU to look at improving nutritional standards on this ward. This involves additional Dietetic staffing to improve training, review of the equipment available for measuring nutritional status and trialling strategies to improve provision of high-quality nutrition on the ward. Learning from this project will be rolled out to the wider Trust.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 3 · response
Published 9 January 2026

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

Require admission and weekly MUST screening, real-time monitoring, automatic Dietetics referral for high risk or poor intake, and multidisciplinary review of repeated nutrition or hydration refusal.

Verbatim wording from the response

“Completing the Malnutrition Universal Screening Tool (MUST), a tool used to identify adults who are malnourished or at risk of malnutrition, is now required on admission and weekly as a minimum. These should be monitored by ward Matrons and Heads of Nursing using the LiveFlo system, if a MUST score is 2 or above or there is documented poor oral intake for more than 48 hours this will trigger an automatic referral to Dietetics. In addition, nutritional plans must be clearly referenced within daily nursing documentation and where patients repeatedly refuse nutrition or hydration, this will trigger a multidisciplinary review (MDT) involving Dietetics and the Learning Disability Nurse, ensuring that barriers to intake are explored and addressed promptly. These measures are designed to ensure that nutritional concerns are escalated early and managed proactively.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 2 · response
Published 9 January 2026

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 specialist Learning Disability Nurse review within 48 hours of admission for patients with learning disabilities.

Verbatim wording from the response

“Any unresolved pain following simple analgesia, or pain reported by carers, triggers a same-shift senior nurse review and medical escalation. In addition, the Learning Disability Nurse completes and documents a specialist review within 48 hours of admission for all patients with a learning disability.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 1 · response
Published 9 January 2026

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

Use the electronic pressure-ulcer audit tool for monthly ward audits and monitor compliance against prevention and management criteria.

Verbatim wording from the response

“As such there have been several actions that have since been undertaken since April 2024 to achieve and maintain long term effectiveness with our improvements. These have been led by the Pressure Ulcer Steering Group (PUSG) and the Tissue Viability Specialist Nurses. We have identified areas for improvement including maternity, elective care, and gateway areas. A new electronic audit tool was designed and implemented in August 2025 after a pilot, whereby audits are now undertaken monthly by each ward auditing a minimum of 20 patients.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 3 · response
Published 9 January 2026

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.8

  1. 1

    Implement Martha’s Rule through Trust communications, posters, a dedicated lead nurse, required escalation, and monitoring of activations and outcomes.

    Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
  2. 2

    Require Hospital Care Plans to be uploaded to Nevercentre and referenced in daily care documentation for current patient information.

    Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
  3. 3

    Improve use of patient passports through a Trust-wide initiative and enhance communication with patients with learning disabilities and their carers through a theatre-specific project.

    Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
  4. 4

    Strengthen Learning Disability Nurse involvement in complex or prolonged admissions through renewed awareness across clinical teams and prompt MDT participation.

    Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2026.
  5. 5

    Require early IMCA referral for high-risk decisions involving patients lacking capacity and without family advocates.

    Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
  6. 6

    Audit IMCA-referral timeliness within six months and continue Learning Disability Nurse reporting to safeguarding and quality forums.

    Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
  7. 7

    Develop a business case for one additional Learning Disability Nurse per ESHT site to improve coverage and responsiveness.

    Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
  8. 8

    Provide pressure-damage prevention leaflets to at-risk patients and those with pressure damage, supporting documented discussions with patients, carers, and relatives.

    Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.

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 Martha’s Rule through Trust communications, posters, a dedicated lead nurse, required escalation, and monitoring of activations and outcomes.

Verbatim wording from the response

“A theatre-specific project is also underway to enhance communication with patients with learning disabilities and their carers. The Trust acknowledges that patient passports are inconsistently updated and used, and a Trust wide initiative, supported by the Transformation Team, will raise awareness and improve staff understanding of how to use passports effectively. Where concerns persist or remain unresolved, staff are required to escalate via Martha’s Rule if carers or family have not already done so. Since September 2025, intensive work has been undertaken to raise the profile of Martha’s Rule through Trust communications, posters, and the appointment of a dedicated nurse to lead its implementation.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 6 · response
Published 9 January 2026

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

Require Hospital Care Plans to be uploaded to Nevercentre and referenced in daily care documentation for current patient information.

Verbatim wording from the response

“Regarding patients who lack capacity and have no family advocate available, an early referral to an Independent Mental Capacity Advocate (IMCA) is now required for all high-risk decisions. This ensures that patients receive the necessary support at the earliest opportunity. Hospital Care Plans must be uploaded to Nevercentre and actively referenced within daily care documentation so that staff have immediate access to up-to-date information on the patient’s needs, risks, and agreed approaches to care. Learning Disability MDT oversight is expected for all complex or prolonged admissions. While this should already occur, with MDTs inviting the Learning Disability Nurse into discussions early in the patient’s journey, this does not always happen consistently.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 6 · response
Published 9 January 2026

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

Improve use of patient passports through a Trust-wide initiative and enhance communication with patients with learning disabilities and their carers through a theatre-specific project.

Verbatim wording from the response

“A theatre-specific project is also underway to enhance communication with patients with learning disabilities and their carers. The Trust acknowledges that patient passports are inconsistently updated and used, and a Trust wide initiative, supported by the Transformation Team, will raise awareness and improve staff understanding of how to use passports effectively. Where concerns persist or remain unresolved, staff are required to escalate via Martha’s Rule if carers or family have not already done so. Since September 2025, intensive work has been undertaken to raise the profile of Martha’s Rule through Trust communications, posters, and the appointment of a dedicated nurse to lead its implementation.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 6 · response
Published 9 January 2026

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

Strengthen Learning Disability Nurse involvement in complex or prolonged admissions through renewed awareness across clinical teams and prompt MDT participation.

Verbatim wording from the response

“Regarding patients who lack capacity and have no family advocate available, an early referral to an Independent Mental Capacity Advocate (IMCA) is now required for all high-risk decisions. This ensures that patients receive the necessary support at the earliest opportunity. Hospital Care Plans must be uploaded to Nevercentre and actively referenced within daily care documentation so that staff have immediate access to up-to-date information on the patient’s needs, risks, and agreed approaches to care. Learning Disability MDT oversight is expected for all complex or prolonged admissions. While this should already occur, with MDTs inviting the Learning Disability Nurse into discussions early in the patient’s journey, this does not always happen consistently.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 6 · response
Published 9 January 2026

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

Require early IMCA referral for high-risk decisions involving patients lacking capacity and without family advocates.

Verbatim wording from the response

“Regarding patients who lack capacity and have no family advocate available, an early referral to an Independent Mental Capacity Advocate (IMCA) is now required for all high-risk decisions. This ensures that patients receive the necessary support at the earliest opportunity. Hospital Care Plans must be uploaded to Nevercentre and actively referenced within daily care documentation so that staff have immediate access to up-to-date information on the patient’s needs, risks, and agreed approaches to care. Learning Disability MDT oversight is expected for all complex or prolonged admissions. While this should already occur, with MDTs inviting the Learning Disability Nurse into discussions early in the patient’s journey, this does not always happen consistently.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 6 · response
Published 9 January 2026

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 IMCA-referral timeliness within six months and continue Learning Disability Nurse reporting to safeguarding and quality forums.

Verbatim wording from the response

“Audits will review the timeliness of IMCA referrals with the first audit scheduled within six months and the Learning Disability Nurse will continue to report into Safeguarding and Quality forums to ensure appropriate oversight and organisational learning.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 6 · response
Published 9 January 2026

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 a business case for one additional Learning Disability Nurse per ESHT site to improve coverage and responsiveness.

Verbatim wording from the response

“The Trust currently employs a single Learning Disability Nurse whose role is to act as a subject matter expert, advisor, and lead for complex cases. A business case is being developed to explore additional support, with the aim of appointing one additional Learning Disability Nurse per ESHT site to improve coverage and responsiveness. Additionally, as a potential alternative, the Learning Disability Nurse is exploring with local support groups and the Trust’s volunteer services how volunteers may help maintain more regular contact with patients with learning disabilities and their carers and feeding back relevant information to the Learning Disability Lead.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 6 · response
Published 9 January 2026

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 pressure-damage prevention leaflets to at-risk patients and those with pressure damage, supporting documented discussions with patients, carers, and relatives.

Verbatim wording from the response

“To improve the standard of information and communication with patients and their carers, during ‘Stop the Pressure’ week in November 2025 the Trust launched new patient information leaflets ‘how to prevent a pressure sore’ (attachment C). The leaflet was adapted from a national document designed by patients for patients in collaboration with the then National Wound Care Strategy (NWCS). The leaflet is provided to all patients assessed as at risk of pressure damage or that have pressure damage. It provides clear information for staff to discuss with patients and includes an area for documentation of individual patient choices or specific advice given. It remains with the patient during the hospital stay and, in the home, and can also be used for sharing treatment plans with carers and relatives.”

Source location

Response from East Sussex Healthcare NHS Trust
Page 4 · response
Published 9 January 2026

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