North Middlesex University Hospital NHS Trust

5. Miss L complains the Trust did not appropriately assess and manage her father, Mr L’s, pressure ulcers during his stay in January 2023. She is concerned it did not involve a tissue viability nurse enough.

6. As a result, Miss L explains her father’s pressure ulcers caused him extreme pain and discomfort. She explained he was no longer able to take part in leisure activities in the care home because the ulcers affected his mobility, making him bed bound. Miss L and her family have also suffered distress, due to witnessing Mr L in pain.

7. Miss L would like an apology, service improvements and a financial remedy.

8. Mr L had lewy body dementia. This is a common type of dementia which causes problems with mental abilities, hallucinations, movement and sleep.

9. The Trust admitted Mr L to a ward on 6 December 2022 and conducted a skin assessment within six hours. This found he had skin discolouration on his right side, most of his bottom legs, and arm.

10. On 9 January, a TVN assessed Mr L and recommended a position change every two hours, and to keep the ulcers dry.

11. The ward transferred him to a stand down ward on 13 January 2023, with a pressure sore on his foot.

12. The Trust conducted a risk assessment related to pressure sores on 13 January, and Mr L scored 17 on the Waterlow scale (a scale used to assess the risk of pressure ulcers, includes factors like body mass index and visual skin assessment). The plan was for staff to assess him weekly.

13. On 17 January, a nurse assessed Mr L and scored him 27, which indicated he was at an extremely high risk at developing ulcers. The Trust then decided to assess him daily.

14. On 22 January, a nurse assessed Mr L and documented redness on Mr L’s sacral region (the bottom of the spine).

15. On 23 January, a nurse documented a category two sacral pressure ulcer. A category two pressure ulcer is generally characterised by partial thickness skin loss which affects the top and bottom layers of the skin but does not extend into the fatty tissue beneath. They usually have a red base and can resemble a blister containing clear or yellow fluid.

16. He also had a category one pressure ulcer on his right buttock. A category one pressure ulcer appears as a discolouration of the skin, usually purple or blue in people with dark coloured skin. The area maybe painful, but the skin is still intact.

17. The Trust nursed Mr L on a dynafoam pump mattress (designed for those considered high risk of pressure ulcer development) and changed his dressings regularly.

18. On 26 January, the Trust recorded Mr L had two sacral pressure ulcers, and one on his right buttock.

19. The Trust discharged Mr L to his care home on 2 February 2023. Mr L sadly died in February 2026.

23. We have considered how the Trust assessed, and managed Mr L’s pressure needs during this admission. Mr L was admitted on 6 December and a TVN assessed him on 9 January.

24. The NICE quality standard says healthcare professionals should conduct risk assessments within six hours of admitting the patient.

25. We can see the Trust conducted an initial skin assessment for Mr L on 6 December, within six hours of admitting him to hospital. This assessment highlighted that he ‘had no pressure damage but there was skin discoloration on his right side, most of his bottom legs and arm’.

26. The Trust has acted in line with the NICE quality standard here in undertaking the initial assessment within six hours.

27. Our adviser explained Mr L was considered high risk due to his lewy body dementia, which affected his mobility, and the pre-existing discoloration of his skin.

28. The NICE prevention and management guidance says that for those who have been assessed as being at high risk, an individualised care plan should be developed and documented. This should take into account the outcome of risk and skin assessment, the need for additional pressure relief, ability to mobilise and reposition, other comorbidities and patient preference.

29. There does not appear to be any evidence to indicate the Trust developed an individualised care plan for Mr L considering he was at high risk of developing pressure ulcers. We have found the Trust failed to act in line with the NICE prevention and management guidance.

30. The NHS Improvement guidance sets out the SSKIN five step-model for pressure ulcer prevention. The SSKIN care bundle is a powerful tool that takes into account the Surface, Skin inspection, Keep Moving, Incontinence Management and Nutrition.

31. By checking the skin more regularly when delivering care, early signs of pressure damage will be identified sooner by staff and carers, instructs staff to document the frequency of repositioning patients, and to develop an individual care plan for them if the patient is at high risk of developing pressure ulcers. The bundle also makes the process of preventing pressure ulcers visible to all. The Trust uses the SSKIN framework.

32. The NICE prevention and management guidance says adults who have been assessed as being at high risks of developing a pressure ulcer should change their position frequently and at least four hourly. If patients are unable to reposition themselves, help to do so should be offered, using appropriate equipment if needed.

33. Mr L required regular repositioning which the documentation supports he was unable to do himself. We know on admission to the Trust, Mr L was at high risk of developing a pressure ulcer, so we think he required assistance to reposition every four hours.

34. We can see that on 7 December, the Trust completed the SSKIN and intentional comfort rounding at 11.03am. This was not completed again until 10.32pm. On 8 December, the Trust completed the SSKIN and intentional rounding at midnight, 7.05am, 5.26pm, 8.48pm and 10.39pm. On 9 and 10 December, the Trust completed the SSKIN and intentional comfort rounding twice each day. The frequency of the SSKIN and intentional comfort rounding then increased to around four to six times a day.

35. These records do not indicate Mr L’s position. If we accept the Trust repositioned him when completing the comfort rounding, there are still periods longer than four hours between the intentional rounding.

36. We have also considered what happened after the TVN assessed Mr L on 9 January. The TVN assessed Mr L at 5.55pm, and they advised the staff to reposition Mr L two hourly and to keep his wounds dry.

37. The SSKIN and intentional comfort rounding was not completed after this until 10.22pm. The following day it was completed at 3.57am, 1.20pm, 2.59pm, 6.23pm, and 11.23pm. The next day, it was completed at 2.16am, 4.40am, 10.17am, 6.48pm, and 10.08pm. The day after, it was completed at 2.41am, 5.02am, 10.16am, 2.49pm, 5.42pm, 7.22pm and 10.16pm.

38. Again, the records do not indicate Mr L’s position. We can again see gaps longer than two hours in the Trust reviewing Mr L.

39. The SSKIN and intentional comfort records from 14 January are completed more frequently, but there are still gaps of longer than 2 hours on occasion. These records do document Mr L’s position, but we think there are some inconsistencies in the records.

40. Part of intentional comfort rounding includes assessing and monitoring skin care for pressure ulcer prevention. We can see the documentation asks ‘Is pressure damage/MSAD (Moisture-Associated Skin Damage) present’.

41. We know on admission, the Trust noted extensive discolouration to Mr L’s skin. On all of the dates that the chart was completed prior to the 28 January, staff have entered ‘N’. The skin inspection section on the form only instructs staff to enter ‘N’ if ‘all pressure areas are intact, no pressure damage, redness or discolouration’. It is therefore unclear why the Trust noted ‘N’ in the assessments.

42. The Trust’s complaint response says that ‘On 23rd January 2023, the nurse documented category two sacral pressure ulcer and a category one right buttock pressure ulcer. Two hourly repositioning was maintained, and Mr L was nursed on a dynafoam pump mattress and dressing were continually changed’. However, the SSKIN and intentional comfort round records for 23 and 24 January 2023, answer the ‘pressure damage/MSAD present’ question as ‘N’.

43. Similarly, the nursing entry from 27 January notes a grade two ulcer, with the dressing intact. The comfort rounding documentation for 26, 27 and 28 January all note there is no pressure damage or moisture associated skin damage.

44. In light of the conflicting information above, we have found there is not enough evidence to say the Trust assessed and managed Mr L’s skin appropriately. The Trust’s records are inconsistent, documenting that there was no skin damage present on the SSKIN charts, when there were potentially pressure ulcers present.

45. We then looked specifically at the involvement of the TVN. We can see the ward referred Mr L to the TVN service on 9 January. We have set out above the TVN’s recommendation following this assessment, and whether we think the Trust followed these.

46. The NMC Code says nurses must refer the skills, expertise and contribution of their colleagues, referring matter to them when appropriate. Our adviser has highlighted the Trust should have requested a further TVN assessment for Mr L on 23 January, when the Trust noted he had pressure ulcers.

47. There does not appear to be enough evidence to suggest the Trust involved the TVN, even after the ward nurse identified two sacral pressure sores. At this point, Mr L’s skin condition had deteriorated, and his care had developed from prevention to include management. The TVN should have been involved at this stage, to provide advice on both further prevention, and management.

48. Therefore we have found the Trust failed to involve a TVN more frequently, especially after identifying two sacral pressure sores on 23 January.

49. In summary, we have found the Trust failed to put in place a care plan and provide consistent pressure ulcer prevention care in line with the NICE prevention and management guidance. We have also found the Trust did not involve a tissue viability nurse when it should have done, in line with the NMC Code.

50. In terms of impact, we have found this led to Mr L experiencing pain and distress during his stay in the hospital. This was for a period of approximately eight weeks. It was understandably distressing for Miss L to witness her father in pain due to the pressure sores, particularly knowing this may have been avoided if the care had been in line with the guidance.

51. However, we do not think we can say the failings affected Mr L’s mobility and made him bed bound, which impacted his social life. We note on 6 December 2022, Miss L informed the doctor in a telephone discussion that her father was ‘not getting out of bed and last sat out in chair on Sunday (4 December)’.

52. On 7 December, Mr L required a hoist transfer with the assistance of two members of the hospital staff. From a mobility perspective, this is the same condition as when the Trust discharged him. Therefore, upon admission, Mr L did not appear to be in a mobile condition.

53. Our adviser also explained his overall deterioration in health and advancing frailty are more plausible explanations for him being bed bound, rather than the impact of pressure sores.

54. We acknowledge this was distressing for Miss L to see. We hope we have explained why we cannot say this occurred as a result of the failing we have found.

55. We acknowledge how distressing developing pressure sores was for Mr L, and how difficult it was to be in pain from these for a prolonged period. We recognise this was distressing for Miss L to witness, particularly given the concern this may have been avoided with more appropriate care.

Our current thinking on recommendations

56. In summary, we have found the Trust’s failings led to Mr L experiencing pain and distress which could have been avoided. We recognise how difficult it was for Miss L to witness this, and that she was caused avoidable worry and distress.

57. In considering our recommendations, we have referred to the NHS Complaint Standards. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should apologise and take steps to put things right.

58. These also say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. We recommend the Trust apologises to Miss L for the worry and distress caused by the provisional failings we identified. We ask that it does this within four weeks of our final report.

59. We also ask that, within three months of our final report, the Trust produce an action plan to show how it has learnt from what happened.

60. The NHS Complaint Standards also state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

61. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, we think the Trust should pay Miss L £800 in recognition of the lasting impact witnessing her father in pain and distress because of the failings. We ask that it does this within four weeks of the date of our final report.

62. We acknowledge the difficult time Miss L has experienced and do not underestimate the impact this has had on her and her family. We understand how difficult it was for Miss L to bring the complaint to us, and we thank her for doing so.

1. During our investigation, we have identified failings that North Middlesex University Hospital NHS Trust (the Trust) did not appropriately assess and manage Mr L’s pressure ulcers, and it did not involve a tissue viability nurse (TVN) enough.

2. We think this resulted in Mr L suffering from pain and distress. This was distressing for Miss L to witness, and we think it could have been avoided.

3. We do not think the failings affected Mr L’s mobility and led to him being bed bound. We acknowledge this was distressing for Miss L, but we do not think this occurred because of the failings we have provisionally identified.

4. We partly uphold Miss L’s complaint and will make recommendations for the Trust to put things right. We ask that the Trust apologise to Miss L for the distress the failings caused and pay her £800. We also think the Trust should put an action plan in place to try and prevent similar failings from occurring in the future.