When a Pressure Ulcer Expert Witness Reviews Avoidable Harm in Long-Term Care

How miscalculated risk scores and care gaps led to a preventable wound

A 90-year-old patient recovering from orthopaedic surgery, was transferred to hospital for rehabilitation. Over the following months, she developed multiple avoidable pressure injuries, despite early signs of elevated risk. An Apex pressure ulcer expert witness was instructed to assess whether the nursing care met expected standards.

The findings revealed repeated Waterlow miscalculations, gaps in SKIN bundle documentation, poor repositioning protocols, and unclear mattress usage. All of which contributed to a breach of duty.

Where the Waterlow risk assessment broke down

The Waterlow score, intended to guide preventative measures, was calculated inconsistently:

• Orthopaedic trauma points were sometimes omitted, despite recent surgery

• BMI was incorrectly calculated on most occasions

• Documentation showed flip-flopping scores, failing to reflect sustained high risk

• Required scores on transfer between wards were frequently missing

  
  

“An elderly woman with hip trauma, diabetes and immobility should have been scored ‘very high risk’ throughout. The inconsistency here demonstrates systemic failure, not a one-off mistake.”— Apex Pressure Ulcer Expert Witness

This misclassification meant critical safeguards like air mattresses and pressure cushions were delayed or inconsistently applied.

Why repositioning records didn’t reflect safe practice

Despite a care plan prescribing 2–4 hourly turns, repositioning charts revealed:

• Gaps of 8–13 hours without documented turns

• Extended time in bed or chair without pressure relief

• No consistent rotation between lying positions (e.g. left/right side)

When pressure injuries appeared, turning protocols were not escalated, and wound care remained undocumented for weeks. Some pressure-relieving equipment was removed without proper rationale, posing further risk.

Lessons from a pressure ulcer expert witness

This case reinforces the legal and clinical risks of failing to apply consistent pressure injury prevention strategies. Any pressure ulcer expert witness would expect:

1. Consistent Waterlow scoring with accurate orthopaedic weighting

2. Robust documentation of SKIN bundles and repositioning

3. Early escalation to dynamic mattresses when mobility reduces

4. Clear rationale for equipment changes, logged in patient records

5. Immediate and well-documented wound assessment and care planning

Had these principles been followed, the Claimant's skin breakdown would likely have been avoided.