A Clinical Risk Case Study- Failure to Treat a Pressure Ulcer

Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Ms Savine BSc, Lead Nurse for Tissue Viability.

The Scene

An elderly Patient with early onset dementia attended A&E for a respiratory infection. It was also noted on admission that the Patient was complaining of hip and knee pain and a fracture was suspected.

Once admitted to the Medical Assessment Unit (MAU) a urinary catheter was inserted which was later noted to be bypassing, resulting in excess moisture from the urine collecting in the Patient’s sacrum. Due to ongoing hip and knee pain, the Patient struggled to self-position in bed and was unable to call for help or relay concerns due to their deteriorating mental health.

72 hours after admission, a grade 3 pressure ulcer had developed, and the Patient was also diagnosed with a fractured hip. TVN input was requested and frequent repositioning recommended. Unfortunately, the pressure ulcer continued to deteriorate into a grade 4 ulcer.

TMLEP’s Independent Clinical Findings

Pressure ulcers are easily avoidable, however, unfortunately they still arise in a hospital setting, and when they do they can be life threatening. Pressure ulcers develop as a result of pressure being exerted on an area of skin which causes the blood flow to that area to be compromised, resulting in necrosis being induced into the affected area. Pressure ulcers can develop in patients of any age; however, they are typically more common in patients who:

  • Are over 70 years old

  • Smoke or have a history of smoking

  • Are confined to bed with illness

  • Have difficulty moving

  • Suffer from obesity

  • Have incontinence issues

  • Have a poor diet

  • Suffer from a condition affecting the blood supply in the body

TMLEP’s independent clinical review concluded that in this Patient’s case, a preventable grade 4 pressure ulcer developed due to the following factors:

A Delay in recognising and treating a fracture

Unfortunately, although the medical team on admission noted that the Patient was complaining of hip and knee pain and a fracture was suspected at the time, this was not documented and subsequently not followed up by MAU. As a result, the Patient was disadvantaged as they were unable to easily re-position in bed, resulting in pressure being concentrated on their skin where they were laying, and this directly contributed to the development of a grade 4 pressure ulcer.

Poor record keeping

Throughout the Patient’s stay in hospital the standard of medical notes, recordings and checks were extremely poor, and not in keeping with the NMC Code of conduct. The lack of ongoing information obstructed care being provided consistently between wards and ward rounds, which resulted in a delay in treating both the hip fracture and the pressure ulcer.

Unnecessary catheter use

There was no medical justification to insert a catheter for this Patient upon admission to MAU. Once it had been identified that the catheter was leaking, protection in the form of barrier creams or films were not applied. The leaking catheter resulted in excess moisture building up around the Patient’s sacrum, encouraging a pressure ulcer to develop.

Inadequate risk assessment scores

Once a pressure ulcer had been identified in MAU, the Patients Waterlow score was calculated incorrectly, which delayed the Patient being placed on a pressure reliving mattress and this therefore, contributed to the continued development of the pressure ulcer.

As an elderly patient, with a deteriorating mental health and who had difficulty moving, the Patient should have been classed from the outset as very high risk and therefore, in addition to the use of pressure relieving equipment earlier, checkups and repositioning should have occurred every 1-2 hours. Unfortunately, this did not occur preventing the Patient receiving appropriate preventative care.

A late referral to a TVN

Where specialist TVN advice is available, it is imperative this is sought early to ensure all possible pressure relieving steps can be taken. Unfortunately, in this case this was delayed.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety:

 Highlighting the importance for accurate record keeping

It is imperative that record keeping is maintained to a high standard and records are passed on to the admitting ward where necessary in accordance with the NMC Code of Conduct (2015). A failure to maintain records adequately can result in a number of issues when it comes to managing pressure ulcers, such as obstructing ongoing care pathways, causing handovers to be inadequate and preventing a patient being appropriately monitored and risk assessed, as this case highlights.

Highlighting the need to calculate Waterlow (or equivalent) scores correctly

It is crucial that Waterlow scores are correctly calculated to ensure patients receive the appropriate preventative care treatment. Where staff are unfamiliar with this, healthcare providers should be able to provide training as required and methods to ensure calculations are undertaken correctly.

Highlighting the importance of considering pressure relieving care and treatment

Wards and theatres should consider the use of all equipment available to them that may contribute to the prevention/treatment of a pressure ulcer, especially once a pressure ulcer has been detected.

Barrier films and creams should be used when skin breakdowns are initially identified, and pressure reliving mattresses should always be used. 

A preventative plan of care should be initiated upon admission as per NICE CG 179 (2014) and this should be updated as the patient’s condition improves/deteriorates.

Frequent re-positing is paramount in the care and prevention of pressure ulcers which should all be clearly documented. This is especially important in patients unable to move. NICE CG 179 (2014) suggest that patients without pressure damage should be repositioned as a minimum every 6 hours and those with pressure damage should be repositioned as a minimum every 4 hours. As with all care plans, this should be tailored to the individual patient and the schedule should be set as per the patient’s own tissue tolerance.

Ensuring nursing staff are aware of the risks of pressure ulcers

Nursing staff should be provided with ongoing and updated education in regard to assessing and calculating the risks of pressure ulcers especially in relation to vulnerable patients such as the elderly population.

Management and use of catheter should always be reviewed

Reasons for insertion of a urinary catheter should also be documented clearly in the notes and should not be used unnecessarily, especially due to the subsequent impact a leaking catheter can have, not least of all on the patient’s risk of developing a pressure ulcer. Regular inspections of the catheter should occur and be documented in the clinical record. Once identified, a leaking catheter should always be removed.

If bed pads are used as an alternative method, then more frequent checks should be made to ensure pressure ulcers and lesions are prevented.

To Conclude

In the interests of improving patient safety and healthcare standards, healthcare providers and clinicians themselves should ensure that all nursing staff receive up to date and ongoing education in relation to the risks of the development of pressures ulcers.

In this case, basic steps in nursing care were unfortunately missed that directly contributed to a grade four pressure ulcer developing; the catheter was not inspected to ensure that it was operating properly, risk scores were miscalculated, nursing notes were not adequately maintained, and available pressure ulcer prevention equipment was not used.




Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Ms Savine BSc, Lead Nurse for Tissue Viability. (2018). A Clinical Risk Case Study- Failure to Treat Pressure Ulcers. TMLEP Clinical Risk Case Studies. 1 (9), 1.

Important Notice: This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0)203 355 9796.