Pressure ulcers

Pressure ulcers are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. Many people who are frail and have restricted mobility are at risk of developing ulcers on the points of their body which receive the most pressure. These are known as pressure ulcers, pressure sores, bed ulcers or ulcers. Pressure ulcers start with skin discolouration but if left untreated they can become very deep and infected, and in the worst cases they can be life threatening. With management and care, pressure ulcers can be avoided in most cases.

Pressure ulcers are primarily a clinical issue and should be referred to an appropriate health professional in the first instance. However, they can occur through neglect and/or omission of care (whether deliberate or unintentional). Each individual case should be considered, taking into account the person’s medical condition, prognosis, any skin conditions, and other signs of neglect. These can include poor personal hygiene and living environment, poor nutrition and hydration, and their own views on their care and treatment.

Staff should refer to their own organisation’s policies and procedures on pressure ulcers; as well as other relevant local and national guidelines, protocols, and policies, e.g., National Institute for Health and Care Excellence (NICE) guidance and incident reporting policies.

In situations where the person has mental capacity and has refused treatment and prevention strategies, all standard interventions must be used first to manage risk (e.g., Care Management/Care Plan Approach/Multi-Disciplinary Team/self-neglect procedures) before consideration is given to raising a safeguarding concern. These interventions should involve:

• Clear and evidenced consideration of mental capacity.
• Evidence available to show concerns raised and support sought from a relevant professional.
• Full discussions with the person and/or their next-of-kin or representative.

In situations where there are obvious signs of neglect these should be reported as a safeguarding concern.

Non-reportable concerns

Lower-level concern where the criteria for a safeguarding enquiry is unlikely to be met. However, an internal written record of what happened and what action was taken should be kept. Where there are several low-level concerns, consideration should be given as to whether the criteria may be met for a safeguarding enquiry due to increased risk.

In these cases, it is important that you consider alternative actions to contacting the local authority. These include:

• Follow relevant internal policies and procedures.
• Refer to the NICE guidance on pressure ulcers (2014).
• Refer to the DHSC’s Safeguarding Adults Protocol for Pressure Ulcers.
• Link with local Community Tissue Viability Teams for up-to-date guidance.
• Share information with district nurse or GP. Consideration of specialist support (e.g., Tissue Viability Nurses).

Examples of non-reportable concerns include:

• Single incident of Category 1 or 2 pressure ulcer.
• Category 3 & 4 and suspected deep tissue injury, or multiple Category 2 pressure ulcers where:
  • A care plan is in place.
  • Action is being taken.
  • Other relevant professionals are involved such as Tissue Viability Nurses.
  • There has been full discussion with the person, their family or representative.
  • There are no other indicators of abuse or neglect or unexplained deterioration.

Concerns requiring consultation

Incidents at this level should be recorded, and internal policies and procedures followed. Consultation should be undertaken internally as well as through the Sussex Safeguarding Adults Policy and Procedures. Action should be taken to reduce risk and consultation with the local authority Adult Social Care department considered. Following this you may be requested to formally raise a safeguarding concern.

In these cases, it is important that you consider alternative or additional actions to contacting the local authority. These include:

• Referral to the local authority Adult Social Care department for a social care assessment or a review of existing arrangements.
• Share information with the ICB Quality Team and/or the CQC.
• Complaints or disciplinary processes.

Examples of concerns requiring consultation include:

Category 3 or 4 pressure ulcers and suspected deep tissue injury pressure ulcers, or multiple Category 1 and 2 pressure ulcers, where:

• The care plan has not been fully implemented.
• Deterioration has taken place without explanation – e.g., Category 2 has been re-categorised as a Category 3-4 ulcer.
• It is not clear that professional advice or support has been sought at the appropriate time such as from Tissue Viability Nurses.
• There are other similar incidents of concerns.
• There are possible other indicators of neglect.

Reportable concerns

Incidents at this level should be formally raised as a safeguarding concern with the local authority Adult Social Care department. Consideration should also be given as to whether the police or other emergency services need to be contacted. Ensure Think Family approach if children or other adults may be impacted.

In these cases, it is important that you consider additional actions to contacting the local authority. These include:

• RAISE SAFEGUARDING CONCERN
• If there is an indication a criminal act has occurred, the police must be consulted.
• Immediate safety plans must be implemented.

Examples of reportable concerns include:

Category 3 or 4 and suspected deep tissue injury, where:

• The person has not been assessed as lacking capacity and treatment and prevention has not been provided.
• No risk assessment and/or care plan completed or of very poor quality.
• There are other incidents of abuse or neglect.
• Evidence demonstrates that this is part of a pattern/trend.
• A root cause analysis or investigation has been commenced or is in progress that has identified abuse or neglect.