Pressure Injury Litigation
Injured by poor care
Pressure injuries occur as a result of negligence, meaning compensation may be owed
Pressure injuries (also called pressure sores, pressure ulcers, bedsores or decubitus ulcers) can develop within hours and deteriorate very rapidly if not caught early. This is compounded for those with frail, friable or thin skin, such as the elderly.
What starts as a superficial problem can quickly become an open wound, penetrating the deepest layers of the skin and extending to the muscles, tendons and even bones beneath.
Such extensive tissue damage is often difficult to heal successfully and can be extremely painful. These wounds are also highly vulnerable to infection, causing major health complications, and risking life and limb.
Pressure injuries are entirely unavoidable in the majority of cases, arising due to negligence and inadequate care.
Failure to risk assess early on – or to identify, treat and monitor a developing pressure injury – can cause lengthy, painful and unnecessary suffering.
According to NHS Improvement’s June 2018 Pressure ulcers: revised definition and measurement:
“Pressure ulcers remain a concerning and mainly avoidable harm associated with healthcare delivery. In the NHS in England, 24,674 patients [Data from the NHS Safety Thermometer] were reported to have developed a new pressure ulcer between April 2015 and March 2016, and treating pressure damage costs the NHS more than £3.8 million every day. Finding ways to improve the prevention of pressure damage is therefore a priority for policy-makers, managers and practitioners alike”.
Furthermore, NHS data collated suggests evidence that “about 1,700 to 2,000 patients a month develop pressure ulcers”.
This is a staggering number of patients suffering needlessly, at a huge cost to the NHS.
A pressure injury (also frequently called a pressure or bed sore, a pressure ulcer or decubitus ulcer) occurs when constant pressure is applied to an area of the skin for a prolonged period of time, cutting off the blood supply. Areas where there is little or no subcutaneous fat to provide cushioning are particularly vulnerable, such as the sacral area, spine, heels, ankles and toes. Because the blood supply is impeded, skin damage can accelerate at an alarming rate.
The National Institute for Health & Care Excellence (NICE) defines pressure injuries as, “localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful”.
- Age, particularly the elderly
- Limited mobility, especially those who are unable to reposition themselves perhaps due to recent surgery (commonly to leg, hip, knee or back)
- Being sedated, e.g., coma/prolonged surgery
- Being bedridden due to age, illness or post-surgery
- Being confined to a chair
- Sitting or lying too long in one position
- Having vulnerable, thin or fragile skin
- Pre-existing medical conditions that impede circulation, e.g., coronary artery disease, peripheral vascular disease, cancer, diabetes, kidney failure, multiple sclerosis (MS) and Parkinson’s disease.
- History of pressure ulcers
- Dehydration
- Weight loss
- Malnutrition / nutritional deficiency / poor food or fluid intake
- Incontinence
- Significant cognitive impairment or decline in mental health
- Spinal injuries, particularly of the cervical or thoracic spine
- Obesity
- Record-keeping is vital to success; particularly, risk assessments, body maps, wound charts and photographs
- All too often, hospitals, nursing homes and other care providers are under-staffed, meaning they do not keep thorough records. If you are worried this may be the case, it can be a good idea to keep your own diary.
- Check that a risk assessment has been carried out and is updated regularly.
- Look for Waterlow and Braden assessments. These prevention tools are used by care homes, hospitals and health professionals to assess the potential risk of pressure injury. The lack of a risk assessment tool could indicate negligence.
- Ask for body maps and photographs. Take your own photographs of the wound if you are concerned about accurate recording.
- Make sure that the size of the wound (length, width, depth) is recorded in the care notes – this should be monitored daily, at a minimum.
- If there has been involvement by a specialist, for example a Tissue Viability Nurse, their records will be very important.
Here is a list of some potential areas of loss:
- Pain, suffering and loss of amenity
- Disability
- Scarring
- Mental trauma and stress
- Pressure relieving/redistributing mattresses, cushions and other pressure relieving aids
- Barrier creams and moisturisers
- Care and assistance provided by family, friends and carers
- Treatment and medical expenses
- Incidental expenses
- Feet
- Heels
- Ankles
- Knees
- Back of thighs
- Hip bone
- Buttocks
- Lower back (sacrum)
- Elbows
- Spine
- Shoulders
- PAIN
- Swelling
- Tenderness
- Open wounds
- Pus
- Areas of skin that feel warmer or cooler than others
- Areas of skin that feel firmer or more moist than others
- Unusual changes in skin colour or discolouration
- Clinical dressings are put on too tight – causing sweating/uneven pressure
- Plaster casts are fitted too tight/too loose – causing sweating/friction
- Poor circulation
- Muscle weakness
- Immobility due to fractures /surgery (commonly to leg, hip, knee or back)
- Being bedridden
- Being confined to a wheelchair /wheelchair users
- Sitting or lying for too long
- Having vulnerable, thin or fragile skin
- Pressure relieving equipment – such as special mattresses, cushions, pillows, pads and bootees – to spread and redistribute pressure.
- Altering diet to increase intake of calories and protein.
- Applying emollients and barrier creams.
- Ensuring good hygiene.
- Making sure continence products are changed promptly when soiled.
- Regular repositioning – NICE Guidelines recommend that adults at risk should be repositioned at least every 6 hours; for those at higher risk, this should increase to every 4 hours, or more frequently if required.
- Offloading vulnerable areas, such as the heels or sacrum.
- Ensuring clothing is well-fitted to prevent friction and sheer.
Pressure injuries are categorised according to four grades, or stages, which we have summarised below, with the visual aid of rotting oranges by way of comparison:
Grade 1:
What it looks like: the skin is intact and not broken.
This is the mildest stage. The skin damage doesn’t look too serious as the pressure ulcer only affects the very top layer of the skin which may look discoloured and swollen.
Symptoms: can include pain, burning or itching, and the skin may feel different from the surrounding skin so that it may be firmer or softer, warmer or cooler. The skin may become discoloured in comparison to the surrounding skin.
Healing: Pressure ulcers may take only a matter of days to recover.
Grade 2:
What it looks like: the skin is partially broken
When the sore digs deeper below the surface of your skin, the skin is broken, leaving an open wound, which can look like a scrape or abrasion, or looks like a pus-filled blister. The area is swollen, warm and/or red.
Symptoms: the sore may ooze clear fluid or pus. It will feel tender and painful. The pain is more intense.
Healing: these sores are treatable and should generally get better within a matter of days to weeks with correct care.
Grade 3:
What it looks like: full thickness skin loss
Symptoms: the sore looks deeper and may have a bad smell and may show signs of infection and pus. The tissue in or around the sore is black as if it has died (necrosis) and may look like a deep wound or crater.
Healing: these sores are usually expected to recover between one to four months.
Grade 4:
What it looks like: full thickness skin loss with extensive destruction. The most severe sores. The sore is deep, extending to the underlying muscles, tendons and bones.
Symptoms: the skin has turned black and may show signs of infection. The wound may have a foul smell. Underlying bones, tendons and muscles may be visible.
Healing: this type of sore can take much longer to heal (if at all), often resulting in more serious complications from infection, even necessitating [plastic] surgery and amputation. These sores can put lives at risk and prove fatal if not managed successfully
If very sticky and difficult to remove, they can exacerbate the problem by pulling on (and even tearing) surrounding vulnerable skin, or pulling on the wound itself causing more damage. Imagine removing sticky brown parcel tape from a newspaper – it will rip or at best damage the print underneath.
Some barrier creams designed to protect the skin and reduce the risk of ulcers developing can be ineffective, and don’t help protect the skin from being pulled when dressings are removed around fragile areas of skin.
Just because the pressure sore is dressed, does not negate the need for constant monitoring and offloading. It is essential that a risk assessment is carried out and a care plan implemented, as pressure sores can develop very quickly, within hours, and turn nasty if not treated promptly.
No. Pressure injuries are not normal and do not occur spontaneously, although they are sadly all too common. They are caused primarily by neglect and poor care; a failure to assess risks and to adhere to, or implement, pressure relieving guidelines. If a pressure injury has occurred, you may well have a claim for negligence.
Whether in hospital or a care home environment, most pressure ulcers wholly preventable with proper assessment and management, and arguably should never occur.
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