PFD report

Beryl Holland · Prevention of Future Deaths report

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Issued 25 Feb 2020•Manchester South

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
1

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. Lack of national guidance on managing and reducing pressure-ulcer risks in Emergency Departments
    Part of recurring concern: Inadequate management of pressure ulcers
  2. Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays
    Part of recurring concern: Failure to provide safe ongoing care during prolonged emergency-department staysPart of recurring concern: Inadequate management of pressure ulcersPart of recurring concern: Inadequate wound management for deteriorating wounds
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    Existing NICE guidance addresses pressure-ulcer risk assessment in emergency departments, so no further action is required at this time.

    Stated by National Institute for Health and Care ExcellenceExisting 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

Lack of national guidance on managing and reducing pressure-ulcer risks in Emergency Departments

Wider context from the report

“The inquest heard that Beryl Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps to reduce the risk of pressure ulcers developing/worsening in the Emergency Department. The inquest was told that there is no national guidance relating to the management of/reducing the risks of pressure ulcers developing in an Emergency Department setting. As a result, Trusts will develop their own policies, which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department. ”

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

Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays

Wider context from the report

“The inquest heard that Beryl Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps to reduce the risk of pressure ulcers developing/worsening in the Emergency Department. The inquest was told that there is no national guidance relating to the management of/reducing the risks of pressure ulcers developing in an Emergency Department setting. As a result, Trusts will develop their own policies, which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department. ”

Is this part of a recurring concern?

Yes — Failure to provide safe ongoing care during prolonged emergency-department stays; Inadequate management of pressure ulcers; Inadequate wound management for deteriorating wounds.

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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

Existing NICE guidance addresses pressure-ulcer risk assessment in emergency departments, so no further action is required at this time.

Verbatim wording from the response

“The NICE guideline on the prevention and management of pressure sores (CG179) specifically provides advice to clinicians regarding patients receiving care in emergency department settings.”

Source location

2020-0037-Response-from-NICE
Page 1 · response
Published 28 February 2020

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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

Existing NICE guidance, local NHS policies and the emergency department safety checklist provide relevant arrangements for preventing and managing pressure ulcers.

Verbatim wording from the response

“I am aware that the National Institute for Health and Care Excellence (NICE) has advised you in its response that a clinical guideline is available on the Prevention and Management of Pressure Sores (CG179)¹ and that this guideline provides specific recommendations to clinicians in relation to patients receiving care in emergency department settings if they have a risk factor. It is the view of NICE that this guideline provides relevant guidance.”

Source location

2020-0037-Response-from-the-Department-for-Health-and-Social-Care
Page 1 · response
Published 28 February 2020

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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.1

  1. 1

    Carry out the multi-year NICE Connect programme to improve how guidance is produced and presented, including stakeholder consultation to make information clearer, more accessible and easier to find.

    Stated by National Institute for Health and Care ExcellenceStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2020.

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

Carry out the multi-year NICE Connect programme to improve how guidance is produced and presented, including stakeholder consultation to make information clearer, more accessible and easier to find.

Verbatim wording from the response

“We have initiated a multi-year programme of work called NICE Connect to review all elements of the way we produce and present our guidance and advice. The aim of this quality improvement project is to transform the way NICE produces and presents information to users, to ensure it can be found on our website more quickly and easily and is as clear and accessible as possible. We will be working and consulting with stakeholders throughout this long-term project. Further details of this work can be found on our website.”

Source location

2020-0037-Response-from-NICE
Page 1 · response
Published 28 February 2020

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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