The Nursing Expert View - Mr Lister & Ms Johnson
A common complaint we are instructed (by the Claimant or Defendant in a civil action) to review and consider as nursing experts, is the development of pressure ulcers (also known as pressure sores) whilst a patient was under the care of registered/qualified nursing professionals.
One of the leading nursing expert witness practices, Apex Health Associates, reports around 20-30% of its work involves considering evidence and providing opinions with regards to the development and management of pressure ulcers. Patients developing pressure ulcers is a significant problem that should not be underestimated - NHS Safety Thermometer reported that from April 2014 to the end of March 2015, just under 25,000 patients were reported to have developed new pressure ulcers, and on average 2,000 pressure ulcers are newly acquired each month within the NHS in England.
Pressure sores are areas of tissue that are damaged by excess pressure, shearing or friction forces. They can occur in any patient and are not restricted to the elderly, frail or dying. Severe pressure sores can be horrific injuries and can have life changing effects. Often people imagine a pressure sore as being merely a reddened area or a small wound. In our experience, pressure sores can be, in extreme cases, severe wounds involving muscle, tendon and bones.
The management of the sore (wound) is outside of the focus of this article, but significant pressure sores can take a significant amount of time to heal (if ever fully) and therefore it is essential that both nursing and medical staff understand the importance of prevention.
As with any clinical negligence case the nursing expert examines and considers the evidence to determine if (1) the nursing care equated to a breach of duty and provide an opinion as to whether (2) the breach/es caused (or materially contributed to) the injury complained of.
There are several areas that experts will pay particular attention to when considering this area of care:-
1. Risk assessment (identification of those at risk)
All NHS Trusts, nursing and care homes will have policies and procedures for the assessment of patients in determining if they are ‘at risk’ of developing pressure sores. Often these policies and procedure documents are well written and clear with pathways for the nursing staff to follow.
Organisations will often employ the use of a validated scoring system (such as the Waterlow, Braden or Norton risk assessment scoring system) to be completed by nursing staff shortly after admission and throughout the patient’s journey.
This assessment stage is fundamentally important and often where the nursing care falls down. Commonly, we find that nurses fail to appreciate the patient’s medical history and clinical circumstances, and do not score them correctly.
Another common error is that the nurse identifies the risks correctly (using the scoring system) but then fails to calculate the final score accurately.
This is often clinically significant because many of the organisation’s policies provide pathways dependent of the score reached. Hence, an incorrect score often takes a patient down an incorrect pathway.
Moreover, it is our experience that there is sometimes an over-reliance on scoring systems and a lack of clinical judgment employed. Validated scoring systems are an excellent tool but the nurse should always remember that they are there only to act as guide and to assist them with their clinical assessment.
2. Skin inspections
The recommendation of NICE ‘Pressure ulcers: prevention and management’ (guidance CG179) recommends those who are assessed to be at high risk of developing a pressure sore should have a skin assessment completed on admission and at least daily.
In clinical practice a failing is (1) for the nursing staff not to carry out and document an assessment, or (2) not to conduct and document a thorough skin assessment including all of the criteria within the NICE guidance (skin integrity, colour changes or discoloration, variations in heat, firmness and moisture) or (3) not conduct an assessment of all areas of skin that are susceptible to pressure i.e the tips of the scapula, elbows, sacrum, heels, back of head, knees, iliac crest (hip bones), tops of toes, knees, ears, cheeks, ankles, trochanter, ribs, shoulders.
3. Care planning (prevention)
A good thorough care plan should be produced. The nurse needs to consider the risk assessment and the reasons as to why their patient may be at risk of developing a pressure ulcer. In very general terms, factors should include, but are not limited to:-
• The patient’s presenting medical condition
• The patient’s ability to move and sensation
• Moving and turning (pressure relief/off loading)
• Hydration and nutritional status
• Outcome of the skin assessment
• Drugs and medication
• Patient preference and comfort
• Use of equipment (such as specialist mattresses) and devices
• Patient education
• Infection surveillance and management
The plan should be accurate and clear as to the interventions prescribed and how and when evaluations will occur.
The common mistakes here are nursing colleagues not conducting a sufficiently robust assessment and missing elements that require planning. Moreover, when a patient’s clinical condition changes the care planning sometimes falls below a reasonable standard because the patient is not reassessed and care plans are not reviewed/updated.
4. Enactment of the care plan
Following the assessment of the patient and prescription of care it then needs to be carried out according to the said plan. If nursing care is not carried out to plan (without good documentation as to the variance) then this is likely to fall below a reasonable standard.
We often find that nurses will not adhere to the prescribed care plan and fail to document the reasons for the variance or update and change the care plan.
Throughout the patient’s journey there should be evaluations as to the prescribed care, and, importantly, the effectiveness of the prescribed care. Once the care has been evaluated the care plan should be amended accordingly.
Here, we often find that a care plan is prescribed but the effectiveness of the care is not considered and the care plan is not evaluated.
6. Correct use of equipment
The amount of pressure relieving equipment available on the market is immense. It is often difficult for practitioners, who may move between organisations, to maintain competence with the standard equipment used for pressure relief as this can vary considerably. Accordingly, it is important for practitioners to ensure they understand the equipment available and its uses. Often we find that nurses have not used the correct equipment for their patient and have not sought the advice of senior or specialist staff.
7. Patient education
Patients need to be given sufficient information and education as to the risk of pressure ulcers and actively involved in the planning of their care. They should be educated as to preventative strategies and encouraged to self position. We find that nurses often do not involve the patients in the planning of their care and educate them in preventative strategies. A leaflet on pressure ulcer prevention should be given to the patient/carers to re-enforce the verbal information given.
8. Refusing patient
Assuming a patient has capacity to make decisions they have the right to refuse any medical or nursing treatment. The key issue here is whether the patient has been told of the risks and consequences should they choose to refuse. Conversations should be documented in the patient’s medical and nursing notes. We find that a patient’s refusal is documented but the medical or nursing staff have not documented the explanation of the consequences of their decisions.
In most of the cases we are asked to consider, documentation is (by far) poor and below a reasonable standard. The planning, delivery and evaluation of nursing care should be clearly and logically documented. Often we find a lack of care planning, poor evaluation, or risk assessments partially or not completed.1
Repositioning is often described by nursing staff as pressure area care.
Patients develop pressure damage when the tissues are injured because of pressure impairing blood supply. To prevent injury, it is imperative that a robust and sufficient repositioning regime is considered, prescribed and enacted. This regime should be carried out, as per the care plan and any variance should be clearly documented and the regime/care plan re-evaluated (as required). In practice the frequency of repositioning or the position are not documented as per the regime. In most cases the repositioning is documented as a tick.
Commonly, within the clinical arena, forms and documents are used to record the position of a patient. These forms can be described as many things but include: turning charts, repositioning forms, ward rounding charts & pressure area care/SSKIN charts. The reasonable standard is for these charts to be completed accurately and contemporaneously.
NICE guidance suggests and recommends that adult patients who have been assessed ‘at risk’ to change position every 6 hours and those assessed as ‘at high risk’ to change position every 4 hours. However, the nurse within the clinical arena will make their assessment and prescribe their care accordingly. It could be that the nurse prescribes more frequent turns having examined the patient and forming an opinion that this is required. In practice nurses will often change the position of a bed ridden patient from side to side, alternating with the patient lying on their back. One method of reducing pressure on a susceptible area i.e hips and trochanters is to use the 300 tilt using cushions under the support surfaces to relieve the pressure. When patients are sitting in chairs, pressure area care and repositioning can be merely allowing the patient to stand (or be hoisted), allowing pressure to be relieved and therefore blood to circulate to the high-risk area.
The prevention of pressure sores by frequent repositioning of patients is a widely accepted practice and nurses commonly reposition at risk patients every 2 hours. However, this is based on a myth that Florence Nightingale took 2 hours to reposition every injured soldier on her ward (Crimean War, 1853- 1856), thereby reducing the number of pressure injuries that occurred. Then, in 1961, a research study by Kozlak, which examined a 2-hour turning schedule, also found this reduced pressure Injuries (Krapfl & Gray, 2008). This led to the belief that all at risk patients should be repositioned every two hours. Today we realise that every individual's risk is different and each individual should be repositioned according to need (Hampton and Collins 2003).
The simplest method for this is to examine the tissues and see any reddening as warning that pressure injury is inevitable if action is not taken to relieve the pressure (Hampton and Bree-Aslan, 2009).
11. Devices for prevention of pressure ulcers
In all circumstances the nurse should adhere to the Local NHS Trust policy.
NICE (2014) and EPUAP (2009) suggests a high-specification foam mattress should be used for all patients admitted to hospital and only if this is deemed not sufficient to redistribute pressure, should consideration be given to the use of a dynamic support surface. In practice the use of a high specification mattress in conjunction with a good pressure ulcer prevention care plan including strictly adhered to repositioning schedules based on skin assessments will prevent tissue breakdown.
Consideration of a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or sit for prolonged periods is essential. Patients who are at risk of heel pressure damage should be supplied with specific off loading devices. In practice there is seldom sufficient forward planning regarding the use of seating devices and heel protectors.
The selection of seating devices should be individualised and take in to consideration
• body size and configuration
• the effects of posture and deformity on pressure distribution
• mobility and lifestyle needs
Although chair cushions should be inspected daily this is rarely documented in the care plans or highlighted as part of the care plan especially in chair bound individuals. In practice the tissue viability teams would advise as to the most appropriate surfaces for patients.
12. Pressure Ulcer management
Once a pressure ulcer has been identified it should be accurately graded according to the accepted grading system used throughout the UK (NPUAP/EPUAP).
In order to monitor healing or deterioration of the sore/ulcer clear documentation should be produced. The location, size, temperature, exudate levels, depth should be recorded. In clinical practice it is now common for photographs to be taken and these should be labelled with the date, patient’s name and the location of the ulcer. The ulcer should be regularly reviewed for signs of improvement or deterioration. A care plan should be produced (or current plans updated) to include the management of the ulcer/sore.
In the care plan/s, the nurse should deal with the following:-
• The outcome of the risk and skin assessment and general health status
• Repositioning and pressure relief (off-loading) regime/frequency to be implemented (what can they do for themselves and what needs to be done for them).
• Reference to any manual handling assessment and safety whilst moving
• Patient preference
• Nutritional status and action plan (as required /needed)
• Referral for specialist involvement (if required) for example to the TVN team, dietician, physiotherapy team and medical teams
• Use of equipment
• Patient and carer education and involvement
• Identify care evaluation time points
• Charts and other aids to be used (e.g. rounding, SSKIN or turning charts)
• Any wound care products or dressings to be used
• Frequency of wound care products or dressings being prescribed
• The frequency of wound care reviews and goals
• The need (if appropriate) for referrals to experts such as the Tissue Viability Nurse or dietician and any medical tests or investigations required
• Patient and family education
• Future planning (such as discharge planning)
• Management of any pain and discomfort (as required)
• Nutritional assessment and requirements (as required)
• The requirement for the use of any barrier creams
In practice we find that this information is rarely found in one document. Parts of the plan of care can be found in the pressure ulcer prevention care plan and some in a wound care care plan or sometimes on the SSKIN documentation. There is no standardised practice with regard to the care planning for pressure ulcer management or care planning.
Problems can be encountered on discharge with GPs and District nurses not informed on occasion of any pressure damage or the need for dressing changes or specialised equipment
In order to aid the healing of a pressure sore/ulcer it is essential that the nutritional status of the patient is assessed and considered. Many institutions will use a nutritional assessment tool: one commonly used tool is the ‘MUST’ tool
When a nurse is concerned about the nutritional status of their patient it is common practice for the nurse to instigate a ‘food diary’ (or similar) monitoring the amount of food and drink that the patient is taking.
One of the problems we regularly identify is that the staff caring for the patient do not use the tool correctly and calculate a wrong result.
14. Referral to specialist teams
Nurses should refer to their local policies as to when and how they make referrals for specialist advice (such as the tissue viability team). In general terms, it is common nursing practice to seek the involvement of tissue viability teams once pressure damage has progressed past a Grade 2 injury if hospital acquired or if the patient is admitted to hospital with a grade 2 or above pressure ulcer.
If a nurse is concerned about a patient’s nutritional status it is common practice to refer the patient to a dietician and trust policies will inform the nurse at what nutritional score this should occur.
Regarding moving and handling and mobility issues it is good practice to involve physiotherapists and occupational therapists to ensure patients practice safe transfers and independent mobilisation. In practice this is not consistently completed and very rarely is a home assessment completed to ensure that a safe discharge can be actioned.
NICE 2014 Pressure Ulcer Prevention states that all healthcare professionals should receive education regarding:
• provide training to healthcare professionals on preventing a pressure ulcer, including:
• who is most likely to be at risk of developing a pressure ulcer how to identify pressure damage
• what steps to take to prevent new or further pressure damage
• who to contact for further information and for further action.
Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure ulcer. Training should include
• how to carry out a risk and skin assessment
• how to reposition
• information on pressure redistributing devices
• discussion of pressure ulcer prevention with patients and their carers details of sources of advice and support.
The Law (Ms Sylvester)
Mistakes happen and with the Duty of Candour now in place, there is a positive duty on the medical profession to inform patients when something has gone awry with their treatment.
Negligence remains the main legal pathway for patients to seek recompense for their injuries. As outlined above, pressure sores can leave patients with long term injuries, which affect their daily lives.
Establishing negligence is a complicated process and involves the collation of medical records and usually, the instruction of experts in the relevant fields of expertise.
In order to establish negligence, the following must be proved in each and every case:
1. a “breach of duty” has occurred. In legal terms, Claimants must prove that they received care that no reasonably competent clinician/nurse/medical professional would have given;
2. an injury or worse than expected outcome has occurred; and
3. the breach of duty caused or materially contributed to the injury. This element is called “causation”.
Cases relating to pressure sores often relate to failures to adequately risk assess a patient and take steps to ensure patient safety. Cases can also relate to inadequate and infrequent patient monitoring, failures to turn a patient in the bed, incorrect placement of a bandage or plaster and inadequate quality and/or inappropriate bed/ mattress or chair. T
o assist with establishing a claim, it will be necessary to analyse the relevant medical records, including nursing charts and risk assessments, to establish the facts, together with obtaining factual witness statements from the Claimant and any witnesses.
Independent expert evidence may be required, to assist with identifying whether the treatment provided, fell below an acceptable standard of care. The experts then assist by considering whether the negligent treatment caused or worsened the injury sustained.
Case Study: Kingsley Napley was instructed by an adult Claimant, R, who underwent cardiac surgery. As a result of poor post-operative care, he sustained grade 4 pressure sores to his heels and coccyx, which resulted in long term nerve damage, foot drop and chronic regional pain syndrome.
The negligence centred around failures to adequately risk assess the Claimant, who was clinically obese and had a number of red flag symptoms, which should have resulted in him being managed as a high risk patient for developing pressure sores.
R was awarded significant damages to assist him with daily living and to purchase (much needed) aids and equipment required as a result of the negligent treatment.
Cases such as R highlight the devastating effects pressure sores can have on patients and the long term implications to health and an individual’s way of life.
Scott Lister. Accurate Record Keeping. Independent Nurse. April 2016.
NHS Thermometer - https://www.gov.uk/government/publications/ pressure-ulcers-applying-all-our-health/pressureulcers- applying-all-our-health
Hampton S & Bree-Aslan C (2009) Pressure Care (Part 2) The importance of Assessment. Nursing & Residential Care 11(1): 12-14
Krapfl LA & Gray M (2008) Does regular repositioning prevent pressure ulcers? Journal of Wound Ostomy & Continence Nursing 35(6) 571-577
Hampton S. Collins F (2003) Tissue Viability: The prevention, treatment and management of wounds Whurr publishers. London
Many thanks to;
Ms Susan Johnson Senior Tissue Viability and Wound Care Nursing Expert Apex Health Associates
Mr Scott Lister Medico-Legal Nurse Consultant, Nursing Expert & Non-Practising Solicitor – Apex Health Associates
Ms Laura Sylvester – Senior Associate Solicitor – Kingsley Napley Solicitors London