How a Pressure Injury Prevention Expert Witness Reviewed Deep Tissue Damage in a Complex Liver Patient

Missed care planning, low visibility repositioning, and failure to escalate foot blisters in high-risk care

In this inpatient case, an elderly patient with chronic liver disease and diabetes was admitted with sepsis and deteriorating blood pressure. Despite her fragile skin, repeated hypotension, and immobility, no pressure injury prevention care plan was implemented. Days before discharge, she was found to have large blisters on both feet yet no offloading plan, tissue viability referral, or community nursing coordination occurred.

An Apex pressure injury prevention expert witness was instructed to review the matter. Their conclusion; a failure to complete risk-based planning or escalate early blister signs led to the development of avoidable pressure injuries, including an unstageable heel ulcer.

What the pressure injury prevention expert witness identified as systemic nursing failures

From admission, the patient was known to have:

• Advanced liver disease with episodes of confusion and fatigue

• A high falls risk and limited mobility

• A Waterlow score placing her at clear risk for pressure injury

• Poorly controlled diabetes and skin noted as friable on examination

Despite these factors, the hospital staff did not:

• Implement a SKIN bundle or repositioning plan

• Commence a care plan for pressure injury prevention

• Document consistent repositioning or heel offloading techniques

• Refer to the Tissue Viability Nurse when foot blisters first appeared

• Ensure a post-discharge wound care plan or community follow-up

“This patient’s risk factors were obvious. Pressure injury prevention should not begin when wounds are visible, it must begin the moment risk is identified.”— Apex Pressure Injury Prevention Expert Witness

What a pressure injury prevention expert witness expects in high-risk nursing care

In cases involving critically unwell patients with reduced mobility, liver disease, and diabetes, best practice standards require:

1. Completion of a Waterlow or equivalent risk assessment within two hours of admission

2. Daily risk reassessment and early implementation of a care plan

3. Use of high-specification foam mattresses and heel offloading devices

4. Repositioning every 4 hours for high-risk patients, with accurate charting

5. Escalation to tissue viability or wound care specialists on first signs of skin breakdown

This patient was documented as having had blisters for “a couple of days” before they were noticed, indicating missed skin inspections and a lack of routine repositioning.

Poor discharge planning compounded missed opportunities

After the blisters were noted, the patient was discharged without a wound care plan, TVN referral, or confirmed community nursing follow-up. The blisters worsened at home, and the patient was later diagnosed with:

• An unstageable heel pressure ulcer

• A suspected deep tissue injury on the opposite foot

The expert concluded these injuries were likely caused, or significantly contributed to, by poor pressure care during admission and a lack of post-discharge planning. Without photographs or complete community notes, causation could not be pinpointed precisely, but hospital care fell well below an acceptable nursing standard.