Pressure Points: learning from Serious Case Reviews of failures of care and pressure ulcer problems

in care homes'

Jill Manthorpe & Stephen Martineau

@scwru

Dramatic images

‘Cruel care home owner and nurse who left elderly and vulnerable people in their care in agony with bedsores’ (Mail Online 2013).

Serious Case Reviews to Safeguarding Adult Reviews

(local) Safeguarding Adults Board must arrange for there to be a review of any case in which

• (a) an adult in the SAB’s area with needs for care and support (whether or not the local authority was meeting any of those needs) was, or the SAB suspects that the adult was, experiencing abuse or neglect, and

• (b) the adult dies or there is reasonable cause for concern about how the SAB, a member of it or some other person involved in the adult’s case acted. (see Care Act 2014 & Guidance)

This presentation…

• Covers a set of Serious Case Reviews of incidents in care homes where pressure ulcers were discussed

• Briefly describes pressure ulcers

• Explains why a pressure ulcer is not inevitably a matter that should be reported to Adult Safeguarding

• Analyses what the Reviews found…

Pressure ulcers• Pressure ulcers also known as pressure sores,

decubitus ulcers or bedsores

• Painful and distressing yet, in many circumstances, preventable or treatable

• Approx. 700,000 people in the UK are affected annually, - 20% of long-term care residents are at risk.

• http://www.your-turn.org.uk/

What’s a pressure ulcer?

• A ‘localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear’ (European Pressure Ulcer Advisory Panel 2009).

• UK grades pressure ulcers 1-4 (4 = most severe)

• NICE (2014) recommends using a validated scale to assess ulcer risk and support their clinical judgement, eg Braden scale, Waterlow score, or Norton risk assessment scale

Change under Care Act

‘The simple fact that an adult at risk has a pressure ulcer – even a serious one – is not in itself a reason to suspect abuse or neglect.’ (SCIE 2015).

What SCRs found: Pressure ulcers amid poor care quality

This SCR found poor training and inadequate multi-agency responses to tissue viability concerns. It recommended that self-funders must receive appropriate support from social work staff and other professionals, including contract monitoring staff.

It led to a Council review of care homes and suspension of funding until acceptable standards were operating.

(Bedford Borough & Central Bedfordshire Safeguarding Adults Board 2009a) (BBCB).

Mr S – multiple PU (died post infection)

The coroner described the nursing care received as ‘woefully inadequate’ and death was ‘for want of care by those charged with it’.

SCR recommended that Policy and procedures for tissue viability should be reviewed.

(BBCB 2009b)

The ‘failing home’Amidst a catalogue of problems, a high incidence of pressure sores was noted by the SCR (2 deaths).

Actions of visiting professionals criticised, eg Community Nursing Service; Adult Community Services; GPs (9); police; ambulance service; local Partnership Trust; and the inspectorate failing to recognise problems:

All failed to be ‘eyes and ears’ for safeguarding.

Pressure ulcers were not proved to be the cause of death, but provided cause for concern about institutional neglect

Orchid View (2014)

‘This investigation focused on a similar range of poor practices as those in previous investigations with residents with pressure sores, poor quality dressings, low staffing levels, staff sleeping at night and rudeness towards residents’ (p45).

And relatives often notice: ‘Mr D had been in Orchid View for some 2 weeks for respite when he was taken to hospital, and he died shortly afterwards. Both his wife and their friend expressed their concerns… that a pressure sore had developed while he was at the home’.

But some people ARRIVE with pressure ulcers

Adult B - SCR Nottingham 2011

Main recommendation = single robust assessment process and better cooperation between health and social care, with the view that an overall care coordinator could have improved the assessment process and reduced the risks for Adult B.

Staff completing tissue viability care plans were recommended to follow best practice guidelines.

& some homes find it hard to cope

In BL staff were not competent to correctly assess risks, identify controls or carry out evaluations (re major needs).

Risk assessments did not cover areas eg moving and handling or sufficient details around pressure care.

Systems for audit, monitoring and compliance of risk assessments were not evident.

Support for/within homes• Some failings in multi-

agency working as well as problems with individual practices.

• Other themes include not adhering to NICE guidance and delays in response.

• Relatives may have concerns that pressure ulcers were not being managed appropriately.

Conclusion 1

High risks of pressure ulcers among care home residents thus making problems in care quality particularly serious for residents.

Problems in prevention and treatment are not solely attributable to care home staff but to the extent to which they are supported by NHS professionals, and the wider problems of the sector which make communication, information sharing, accountability and resource provision difficult.

Conclusions 2

SCRs and SARs are likely to be more common following the Care Act –are care homes ready in case…?

But main lessons learned from SCRs/SARs around pressure ulcers relate to internal safeguards and external supports

Key resource

http://nhs.stopthepressure.co.uk/

Acknowledgement & disclaimer

• We acknowledge funding from the NIHR Policy Research Programme.

• The views expressed here are those of the authors and not the NIHR.