Pressure sores: neglect, suffering and a client’s victory

We act for many clients who have developed pressure ulcers as a result of negligent treatment within hospitals, care homes and nursing homes.

What is a Pressure Ulcer?

Pressure ulcers are caused by prolonged and frequent pressure on the skin. They usually occur over bony prominences such as the buttocks, elbows, and spine. Individuals who remain seated in the same position for long periods without movement are at risk of developing pressure ulcers. Additionally, patients who suffer from incontinence issues are also at risk due to increased moisture around the sacrum and buttocks when pads are not regularly changed. It is therefore common for elderly and immobile patients to develop pressure ulcers if they are not provided with the appropriate care and treatment. It is important to ensure that individuals who are at risk of developing pressure ulcers are repositioned regularly to prevent this.

Pressure ulcers can be red, sloughy (with debris that is grey, yellow, or green in colour) and they can become necrotic due to a lack of oxygen caused by pressure cutting off the blood supply to the site of pressure.

Pressure ulcers are assessed as being graded from 1 – 4 using the European Pressure Ulcer Advisory Panel (EUAP). The higher the grade, the more severe the injury.

Grade  1

A Grade 1 pressure ulcer is the least severe type of ulcer. The affected area of the skin is discoloured. There’s no open wound, but it may hurt or itch. It may also feel either warm and spongy, or hard.

Grade  2

In Grade 2 pressure ulcers, some of the outer surface, or the deeper layer of the skin is damaged. Visibly the ulcer looks like an open wound or a blister.

Grade  3

In Grade 3 pressure ulcers, skin loss occurs throughout the entirety of the skin. The underlying tissue is also damaged, but the underlying muscle and bone aren’t. The ulcer is a deep wound.

Grade 4

A Grade 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged and the surrounding tissue is ‘dead’, called necrosis. The underlying muscles or bone may also be damaged. An individual with this stage of pressure ulcer is at high risk of developing a life-threatening infection.

Treatment of pressure ulcers involves creating a care plan that ensures that pressure is not placed on the skin. The care plan will call for regular repositioning and state the frequency of repositioning and skin inspections required, as well as any pressure relieving equipment and wound care needed.

Care and Treatment

Upon admission to a Hospital or care environment, patients should be assessed to determine whether they are at risk of developing pressure ulcers using an assessment tool. The National Institute for Health and Care Excellence (NICE) guidelines indicate that this should be done on the day of admission to the care provider and within 6 hours of admission, with an appropriate care plan then put in place.

The care plan should involve regular, hourly, repositioning and state any medication and equipment required to prevent pressure ulcers from developing and to care for any existing pressure ulcers. Carers and Hospital staff should document the timing of repositioning and how the patient was repositioned. Patient’s wounds should be cleaned with saline/and or appropriate ointments to prevent infection.

The NICE guidelines state that ‘at risk’ patients must be moved every 6 hours, ‘high-risk’ patients every 4 hours and ‘very high-risk’ should be moved every 2 hours.

The patient’s pressure ulcer stage must clearly be stated, and the pressure ulcers must be graded accurately to ensure the appropriate care plan is in place, and the correct treatment administered.

Individuals at risk of developing pressure ulcers must have a minimum of once daily skin inspection to monitor the development of pressure ulcers and mitigate the risk of further pressure ulcers developing.

Body maps should be completed regularly to identify any issues with the patient’s skin integrity, and one should be done on admission to the care provider. Body maps should be completed to identify any lesions on the body.

Individuals who suffer from incontinence should be checked regularly and changed regularly to prevent moisture placing them at risk of developing further pressure sores. Carers should ensure that they accompany patients to the commode every 2 -3 hours to prevent them from defecating.

Nutritional intake should be monitored to ensure that the patient remains healthy and to prevent them from placing their skin integrity at risk. Staff should refer patients to dietitians if there are concerns.

Examples of negligent management of pressure ulcers:

• Failure to assess the patient’s risk of developing pressure ulcers on admission

• Failure to implement a care plan for the patient on admission and a failure to follow the care plan

• Failure to complete daily skin assessments and to Grade  the pressure ulcers

• Failure to reposition the patient regularly as per the care plan and document repositioning

• Failure to monitor the nutritional intake of the patient

• Failure to monitor the patient's toilet needs when incontinent

• Failure to implement pressure relieving equipment when required

• Failure to clean and treat the pressure ulcers to prevent infection

To bring a successful clinical negligence claim, we must be able to attribute a prolonged period of pain suffering and loss of amenity to the patient, which was caused by the care provider’s failure to monitor, and/or treat the pressure sores of the patient. We must satisfy the Court that the negligence has caused pain and suffering to the client, over and above what would have been experienced had the appropriate level of care been provided.

Success Story

Client A was successful in receiving a claim for damages for their deceased 93-year-old elderly family member who suffered from Bullous Pemphigoid, Dementia and significant co-morbidities. The deceased had developed significant pressure ulcers whilst resident at the Defendant’s care home over four months, including a Grade 4 pressure ulcer on the sacrum, resulting in a hospital admission. They also suffered from dehydration and malnutrition. The Grade 4 pressure ulcer to the sacrum was noted to be the secondary cause of death on the Deceased’s death certificate.

This was a complicated case with two defendants; the Care Home, where staff were responsible for the overall care and monitoring of the Deceased and the Tissue Viability Nurses, from a separate NHS Trust, who were responsible for treating the Deceased’s wounds whilst they were resident in the care home. After issuing proceedings the Claimant was compensated for the injury.

If you or anyone you know feels that they may have experienced any of the issues outlined in this article and would like to discuss this, please contact the Clinical Negligence Department on 0800 037 4625, a member of our team will be happy to assist.