The evidence disclosed that Mrs Barrett received optimal care following her transfer from Colchester General Hospital acute care to Trinity Ward in the Fryatt Community Hospital. However, serious concerns were raised in evidence by East Suffolk and North Essex NHS Foundation Trust (ESNEFT) witnesses relating to the impact and consequences of an absence of embedded, dedicated Tissue Viability Nurses (TVNs) and a Tissue Viability Service (TVS) across the two ESNEFT Community Hospital Sites which, together, involve three Wards (including Trinity Ward) with, cumulatively, some 77 patient beds. The Community Hospital Wards are Nurse Practitioner led and based on a GP model but since 2023 have seen the withdrawal of embedded TVNs or a TVS across all Wards. The evidence from both the Colchester General Hospital Matron and the Community Tissue Viability Lead Nurse confirmed that whilst this has been formally recognised as a ‘risk’ - and attempts at mitigation have been attempted - the steps taken have been inadequate. In her evidence the Tissue Viability Lead Nurse confirmed that she had raised and escalated her concerns regarding the change in policy and informed the Court that she had felt it necessary to “block” some transfers of vulnerable patients from the Acute Hospital to the Community Hospital, expressly on the basis that the absence of an embedded TVS gave rise to a serious risk of the deterioration of these frail and vulnerable patients’ pressure ulcers to the extent, she confirmed, that such transfers presented a risk of future deaths. Notwithstanding the ‘blocking’ she has been required to resort to, she made reference to an increase in pressure damage in the Community Hospital Wards in a 2025 three month period compared to the same period in 2024.