Case Study: Skin Tears, Equipment Use, and Nursing Duty of Care

In this case, an elderly woman was admitted to hospital while on holiday. She arrived with pre-existing pressure injuries and vulnerable, oedematous skin. Several days into her stay, she sustained multiple skin tears during a manual handling transfer using a hoist.

Her family alleged that the nursing staff had acted negligently. An independent nursing expert witness from Apex Experts was instructed to determine whether the injuries were preventable and whether the standard of care met accepted professional and regulatory requirements.

Clinical Background - Skin Tears, Pressure Ulcer and More

On admission, the patient presented with:

• A Grade 3 pressure ulcer on the left foot

• Skin tears to both lower legs and arms

• A history of diabetes

   and dementia

Her care plan recognised her vulnerability but did not initially require bed rails or other mechanical restraints. The skin tear incident occurred during a bed-to-chair transfer using a Stedy hoist, with two members of staff assisting and her daughter observing.

An internal hospital review later concluded that the patient had “extremely friable skin” and lower limb oedema — conditions that made her skin exceptionally fragile.

“In frail, oedematous skin, even minimal handling can cause tissue damage — but this does not automatically indicate negligence.”— Apex Nursing Expert Witness

However, documentation inconsistencies raised questions. Notes suggested that the tears may have been caused not by handling, but by contact with bed rails — a potentially avoidable event and, if proven, a breach of the NMC Code and CQC standards for safe care and treatment.

The Expert Witness Analysis

The Apex expert reviewed medical and nursing records, body maps, risk assessments, and incident reports. They found several key shortcomings that affected both patient safety and the hospital’s ability to defend its care:

• Incomplete or conflicting documentation about the mechanism of injury.

• Missing or outdated body maps following the incident.

• Inconsistent risk assessments that failed to reflect the patient’s deteriorating skin condition.

• Limited evidence of manual handling care plans or supervision arrangements.

• No contemporaneous notes on how or when the family was informed.

The expert concluded that the combination of documentation gaps and inconsistent assessments significantly weakened the Trust’s position — even though the injury may, in part, have been unavoidable due to the patient’s fragile skin integrity.

Documentation: The Foundation of Defensible Care

From both a clinical and medico-legal standpoint, this case underscores the importance of clear, structured, and contemporaneous documentation. A defensible record should demonstrate that staff:

• Completed and updated body maps at admission and post-incident.

• Conducted pressure ulcer risk assessments using validated tools.

• Documented moving and handling plans and reviewed them as patient condition changed.

• Monitored and recorded hydration and oedema status.

• Provided accurate details about the mechanism of injury and witness accounts.

In this case, incomplete notes made it difficult to determine the true cause of the injuries — leaving the hospital vulnerable to criticism, even where staff may have acted appropriately.

Wider Lessons for Nursing and Care Settings

Although the incident occurred in an acute hospital, its lessons extend to residential and community care settings where patients with dementia and frailty are frequently moved with hoists or transfer aids.

Best practice includes:

• Documenting all pre-existing injuries and skin vulnerabilities on admission.

• Using protective equipment such as bedrail covers, slide sheets, or limb protectors.

• Ensuring regular tissue viability reviews and prompt escalation to specialist teams.

• Recording family communication after any incident, in line with the Duty of Candour.

These principles reflect national recommendations from tissue viability and patient safety bodies and should be standard across all care environments.

The Medico-Legal Perspective

From a legal standpoint, this case illustrates how documentation failures can be as damaging as clinical ones. Even when harm may be biologically inevitable, poor recording practices make it impossible to demonstrate that care met the expected standard.

In negligence claims, the focus is not only on whether injury occurred, but on whether staff actions were reasonable and evidence-based. Without clear documentation, this becomes difficult to prove.

The Apex expert concluded that:

• The injury itself may have been partly unavoidable, given the patient’s skin fragility.

• However, policy and documentation lapses created avoidable uncertainty.

• Better record-keeping and review would have supported a stronger defence.

Conclusion

This case reinforces a central truth of nursing care: good documentation is part of good care. When policies are inconsistently applied or assessments incomplete, even well-intentioned care becomes difficult to defend.

The nursing team’s compassion and vigilance were not in question — but the absence of complete records, risk reviews, and post-incident mapping created a gap between clinical reality and evidential defensibility.

At Apex Experts, our independent nurse expert witnesses provide CPR Part 35-compliant reports that help clarify whether harm was avoidable, whether professional standards were met, and how documentation and assessment influence the outcome of clinical negligence claims