How are pressure sores classified?
Pressure ulcers are categorised into four levels (grades or stages) which we have summarised below, with the visualised aid of rotting oranges by way of comparison:
Are pressure sores normal and just part of getting old?
No. Pressure sores are not normal, and don’t occur spontaneously on their own. They are caused primarily by pure neglect or failure to adhere to or implement guidelines as to their assessment and management. If a pressure ulcer develops you may well have a claim for negligence.
Whether in hospital or a care home environment, most pressure ulcers are entirely avoidable and wholly preventable with proper assessment and management and arguably should never occur. So much so, that the NHS are introducing a new campaign in December 2018 (to be implemented in April 2019) to help reduce the incidence of pressure ulcers, called: “Stop the Pressure: definition and measurement framework and national curriculum for pressure ulcer prevention.”
What is a pressure sore?
A pressure sore (which we shall refer to as including pressure/bed/skin sore) occurs when pressure or friction is being applied to an area of the skin over a period of time – where there is little or no subcutaneous fat to provide cushioning, or poor circulation cutting off the blood supply, causing damage to the skin and the deeper layers of tissue under the skin – resulting in infection due to poor mobility.
“Pressure ulcers: revised definition and measurement framework” June 2018 redefines a pressure ulcer 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.”
What factors increase risk of pressure sores?
- Age, particularly the elderly
- Significantly limited mobility / or who are unable to reposition themselves perhaps due to post-operative fractures /surgery (commonly to leg, hip, knee or back)
- Under sedation eg a coma/prolonged surgery
- Being bedridden due to age, illness or post-surgery.
- Confined to a wheelchair
- Sitting or lying too long in one position
- Having vulnerable, thin or fragile skin
- Chronic pre-existing medical conditions that affect the blood supply make skin more fragile, difficult to heal or prolong healing, or cause mobility problems –eg coronary artery disease, peripheral vascular disease, cancer, diabetes, kidney failure, multiple sclerosis (MS) and Parkinson’s disease.
- History of pressure ulcers
- Weight loss
- Malnutrition / nutritional deficiency / poor food or fluid intake
- Incontinence (sitting or lying in wet patches)
- Significant cognitive impairment or decline in mental health
What are the common symptoms of pressure sores?
- Open wounds
- 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
What areas are commonly affected by pressure sores?
- Back of thighs
- Hip bone
- Lower back (sacrum)
What are the common causes of pressure sores?
- 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
Beware: Some clinical dressings can cause more problems!
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 avoid the need for constant monitoring and turning – but repositioning can be tricky and difficult after some surgeries. Even so, it is important for a risk assessment to be carried out and a care plan implemented, as pressure sores can develop very quickly and turn nasty if not watched and treated promptly.
How are pressure sores typically managed?
- Pressure relieving devices such as special mattresses – to spread and redistribute the pressure
- Other pressure relieving/pressure reducing or pressure redistributing devices such as cushions, special pillows or pads
- Applying special dressings
- Altering diet
- Improving hygiene
- Cleaning the wound and removing damaged tissue (debridement)
- Repositioning – the NICE Guidelines provide that adults at risk should be turned at least every 6 hours; but if assessed as being at high risk, repositioning should occur at least every 4 hours. If the condition is chronic, we would suggest that repositioning takes place more frequently. Read [https://www.nice.org.uk/guidance/cg179]
Substandard care – What allegations of neglect will help my claim?
Substandard care is care that falls below an acceptable level. Here are some examples:
- Failure to risk assess upon admission – particularly so, if known to be at ‘high’ risk eg have a history of pressure sores
- Failure to take any steps to manage the condition and prevent the pressure sore from occurring in the first place
- Failure to carry out regular (physical) skin inspections and risk assessments thereafter so as to prevent pressure sores developing
- Failure to turn and reposition regularly to minimise the risk of pressure sores developing or getting worse
- Failure to devise and/or implement a care plan to manage the pressure sore
- Failure to provide any or any adequate pressuring relieving devices or aids –eg mattress, cushions, etc
- Failure to monitor and continually observe an individual at risk eg with particularly vulnerable skin
- Failure to exercise, mobilise or rehabilitate (eg physiotherapy) where appropriate.
- Failure to change dressings sufficiently regularly
- Failure to assess and manage continence, nutrition and hygiene etc
- Failure to use special lifting equipment (to avoid skin shearing)
- Failure to involve a Tissue Viability Nurse, where appropriate
- Failing to adhere to their own guidelines or the NICE guidance in respect of tissue viability
- Failure to keep adequate or complete records
What compensation can I claim for?
Here is a list of some potential heads of loss:
- Pain, suffering and loss of amenity
- 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
What evidence will help my claim?
- Check that a risk assessment was carried out upon admission and is updated regularly.
- Look for risk assessments, such as Waterlow Scores or Braden etc in the medical or care records. These prevention policy tools are used by care homes, hospitals and health professionals to assess the potential risk of developing pressure sores. The lack of a risk assessment tool could indicate negligence.
- Appearance: Ask the care home or hospital for photographs of any developing areas that look like they could develop into a pressure sore and keep taking them as proof of development. Make sure you can prove the date they were taken as that will be helpful evidence to support your claim for neglect.
- Complain and tell someone about it – a specialist tissue viability nurse may be needed to do an assessment.
- Record-keeping is vital to success and often hospitals, care homes and nursing homes are under-staffed and, in the main, do not keep good, accurate and up to date records. If maintaining a claim for negligence, documentary proof of neglect can be the key to success.
- Make sure that the size of the wound (length, width, depth) is recorded in the care notes.