14. As defined within NHSI guidance, a pressure sore is an injury to the skin and/or the underlying tissue, usually over a bony prominence or related to a medical or other device, caused by sustained pressure. The damage can be present on intact skin, or as an open sore or ulcer, and may be painful.
15. Pressure sores are categorised in grades from one to four, with one the least severe and four the most. As explained by NHS Inform, a grade one pressure sore may cause the affected area of skin to become discoloured but does not have an open wound, and grade two pressure sores look like an open or burst blister.
16. On her return, the care home photographed the marks and damage to Mrs M’s skin. Our adviser considered the photographs and identified grade two pressure sores on each of Mrs M’s heels, a grade one pressure sore on Mrs M’s left outer ankle and a grade one pressure sore on her sacrum (the triangular shaped bone at the base of the spine).
17. Other photographs show skin marks that our adviser explains are not attributed to pressure damage. For example, some areas of redness do not appear to be over a bony prominence and are not circular or symmetrical in shape. These are factors that mean pressure did not cause that redness.
18. Our adviser says for other images it is not possible to say whether this was pressure damage or not due to the quality of the images, or because physical examination is needed to identify whether the cause was pressure.
19. It remains that from the evidence we have, we find Mrs M had four pressure sores on her return to the care home on 27 February 2024.
20. We first address the sacral sore. The skin assessment completed on Mrs M’s admission to the Trust documented existing redness to her sacrum. Our adviser says what is documented on admission appears consistent with the photo of the sacrum taken by the care home on Mrs M’s return. This area of redness was therefore present before Mrs M’s admission and remained stable throughout her time at the Trust. For this reason, we do not attribute the sacral pressure sore to Mrs M’s care in hospital.
21. Next, the pressure sores on Mrs M’s heels and on her left ankle. The ambulance that transferred Mrs M to hospital documented a swelling of Mrs M’s left foot. On her arrival, assessment in the emergency department (ED) notes the left foot was red and warm. An ED clinician completed their assessment whilst Mr M was present, noting that Mr M said he had received a call from the care home as they were concerned about Mrs M’s swollen foot.
22. Whilst we do not find evidence of specifically pressure damage of the heels or left ankle prior to Mrs M’s admission, these records indicate her left foot was swollen and sore, and concerns had already been raised. This could reasonably have been the start of pressure damage, even prior to her hospital admission.
23. We think this important to note, as there is clear evidence of some skin redness and raised concerns, even before Mrs M arrived in hospital. Yet, it remains we must consider what happened during the admission. We carefully considered whether we could attribute the development of Mrs M’s heel and ankle pressure sores to any poor care or treatment at the Trust. We hope to assure Mr M we do not see any indications of this.
24. NICE CG179 says adult patients should have their pressure sore risk assessed when admitted into secondary (hospital) care. Records show the necessary assessments were completed in line with NICE CG179, finding Mrs M was at high risk of pressure damage.
25. NICE CG179 sets out recommendations for patients found to be at high risk of pressure damage. As this applied in Mrs M’s case, we go through each recommendation in turn.
26. NICE CG179 says these patients should be encouraged to reposition or offered help to change their position frequently, at least every four hours. We find repositioning charts within the records, showing Mrs M was offered and helped with repositioning, in line with NICE CG179. Whilst repositioning did not always take place four-hourly as per one specific recommendation in guidance, this was not due to any inaction on the part of the Trust.
27. Secondary to her confusion and agitation, records note Mrs M would frequently refuse assessments, observations and nursing interventions, and this included repositioning. Records show the times the Trust could not fulfil four-hourly repositioning was for this reason. Our adviser is assured the records show sufficient repositioning care in line with NICE CG179.
28. NICE CG179 says to offer adults with a pressure sore a nutritional assessment by a healthcare professional with the necessary skills and competencies. Records show this was fulfilled by a Trust deputy and senior manager who completed Mrs M’s pressure sore risk assessment with consideration for her nutritional needs and measures during her admission.
29. NICE CG179 says to offload heel pressure as part of the patient’s individualised care plan, with NICE QS89 recommending the use of equipment that offloads heel pressure. Records show the Trust acted in accordance with both pieces of guidance, by ensuring repose boots were in place. These are air filled sacs that sit under the foot with a hollow immediately beneath the heel, ensuring the heel is exposed to no pressure at all.
30. Lastly, NICE QS89 says people at high risk of developing pressure sores should be provided with pressure redistribution devices, such as highspecification mattresses. NICE CG179 also says to use a high-specification foam mattress.
31. Records show that Mrs M was initially nursed on a foam mattress, with early and daily requests by nursing staff to obtain an air mattress. Our adviser confirms Mrs M should have been nursed on an air mattress sooner, as this would have been in line with the above recommendations in guidance. Whilst we acknowledge this delay, we do find records to show nursing staff took concerted steps to make the request and to try and address this delay as soon as resources allowed.
32. In summary, the Trust appropriately assessed Mrs M’s risk of pressure damage in line with NICE CG179, and we do not find indications that the nursing given in relation to her known high risk of pressure damage, was poor. Pressure area care was given in line with national guidance, except for the delayed air mattress. In considering the clear photographic evidence, our adviser is clear in stating this would not have been the direct cause Mrs M’s skin damage.
33. Our adviser explains the cause of Mrs M’s skin damage from pressure or otherwise, was multifactorial. Her infection had caused confusion and agitation, which meant she was at increased risk of accidental skin damage. This is evidence by notes of Mrs M pulling out lines, and her non-compliance with assessments and repositioning. Photographic evidence shows Mrs M had tissue paper skin, a term used to describe thin and fragile skin which is prone to easy damage such as tearing, bruising or marking even without associated agitation.
34. Records show redness to her sacrum, and redness and swelling to her left foot, even before she arrived in hospital. Our adviser says other relevant factors that may have contributed would have included her frailty, poor mobility, and likely reduced nutrition simply due to her condition at that time.
35. Pressure sores can sometimes develop, even when everything is being done to try and prevent them. We hope to assure Mr M, we do not see evidence to suggest the development of his mother’s pressure sores was the result of any indication of service failure in her care and treatment at the Trust.
36. We know Mr M is concerned that the Trust discharged his mother with pressure sores. From the photographic evidence, our adviser confirms Mrs M did not have skin damage that necessitated a longer stay in hospital. This would only have been required if those sores had been much more severe, involving deep wounds and with the presence of wound infection or sepsis.
37. We can assure Mr M this was not the case for his mother, and we do not see any indication of wrongdoing in the Trust’s decision for discharge. Our adviser adds that given her confusion and agitation, she was likely to be more comfortable and compliant with her known carers and within her usual environment.