Pressure ulcers (also known as pressure sores) break down the skin and underlying tissue. They are caused when an area of skin is put under pressure – either a large amount of pressure during a short period of time such as surgery - or a lower level of pressure sustained over a long period (eg an immobile patient remaining in one position for long periods of time).
People with health conditions that make it difficult to move, especially elderly patients who are either bedbound or sit for prolonged periods of time, and those with conditions such as type 2 diabetes or other conditions affecting their blood flow are particularly vulnerable to pressure ulcers. They typically affect areas around the hip, bottom, ankle, elbow or heel.
Healthcare professionals use grading systems to describe the severity of pressure ulcers. The higher the grade, the more severe the injury to the skin and underlying tissue. The most common grading system is of one to four with grade one being a superficial pressure ulcer, usually where the skin remains intact, and grade four being the most severe type of pressure ulcer. In a grade four ulcer, the skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles or bone may also be damaged and the patient has a high risk of developing a life-threatening infection.
When any patient is admitted to a hospital, a risk assessment should be carried out to assess their potential to develop a pressure sore and to identify any existing pressure sores that need managing to prevent progression. The Waterlow pressure ulcer risk assessment/prevention policy tool is, by far, the most frequently used system in the UK. This assessment should consider a range of factors including general health, mobility (both current and expected), existing health conditions, ongoing and planned medical treatment, medication and age.
In many cases, there are no risk factors present and no further preventative management is needed. However, if a patient is considered to be at medium to high risk of developing a pressure sore, then an appropriate management plan should be made, documented and communicated to staff to try to reduce and manage that risk. Steps involved can include provision of special mattresses, clear plans for moving a patient and regular observations. Where such needs are identified and actioned, pressure sores can be avoided. It is generally regarded that a patient under hospital care who develops grade three or four pressure ulcers is a ‘never event’ which should result in a serious incident investigation being carried out.
Sadly, despite clear requirements for pressure sore risk assessments to be properly done and reviewed, there are many claims for clinical negligence each year arising out of pressure sores developing due to negligent care. While, in some cases, the failure is at the outset when insufficient consideration is given to risk factors or even in some cases where the assessment is omitted, the failure is often in implementing the management plan or failing to realise that risk factors have developed and re-assessing the patient.
The Association of Personal Injury Lawyers (APIL) ran a campaign on the need to manage patients better to prevent pressure sores and the cost of follow on treatment. It identified some worrying statistics: from NHS England’s own figures, the cost to the NHS of treating serious pressure ulcers could be as much as £186 million every year and that 95% of pressure ulcers are completely preventable.
Philippa Luscombe, partner in the Penningtons Manches clinical negligence team, comments: “Risk assessment and prevention of pressure sores is one of the most basic requirements in hospital care. But all too often we end up dealing with clinical negligence claims arising out of very basic failings in such nursing care.
“Examples of cases where we have recovered damages include elderly and diabetic patients whose existing low level pressure ulcers are not properly managed and progress during an inpatient stay; documented plans for observations and turning not being followed; and patients who initially attend hospital as low risk patients becoming high risk due to immobility and failure to re-assess. Although many people assume that pressure ulcers are unpleasant but manageable, they can, in fact, become extremely dangerous if they are allowed to progress. At best the patient will need prolonged treatment and sustain permanent damage while worst case scenarios are sepsis and death.
“As the APIL campaign highlighted, with basic procedures in place many pressure sores should never develop and this is an area of health care that has to improve.”
For advice on investigating concerns about pressure sores please contact us free of charge on 0800 328 9545 or email us at email@example.com.