When Waterlow Scores Go Unquestioned: A Case Review from a Pressure Ulcer Expert Witness

How a misjudged risk score and absent prevention plan led to preventable injury

In this case review, a senior pressure ulcer expert witness examines how inconsistent use of the Waterlow scoring system, alongside missed nursing interventions, allowed a high-risk patient to deteriorate without the necessary safeguards in place. Despite early indicators of vulnerability, appropriate care planning was delayed or omitted altogether, with fatal consequences.

Misjudged pressure injury risk and missed nursing interventions

Pressure ulcers often begin with a breakdown in communication and not just within a team, but between clinical tools and clinical judgment. In this case, the Waterlow score, intended to guide pressure ulcer prevention, was incorrectly calculated on multiple occasions.

Although the patient presented with significant weight loss, decreased mobility, and an extended inpatient stay, his scores reflected a "low-risk" status. The actual risk was markedly higher with calculations that, if done properly, would have triggered interventions such as:

• A comprehensive skin inspection and mapping

• A robust, detailed care plan

• Access to appropriate pressure-relieving equipment

• Regular documentation of repositioning

• Implementation of a SKINN bundle for consistent monitoring

Instead, Waterlow entries were logged without explanation or rationale, leaving reviewers unable to trace how scores were derived. This disconnect between documentation and clinical risk represents a systemic flaw in patient safety management.

"This patient should have been identified as high risk from the outset. A proper Waterlow score would have changed the trajectory of care from reactive to preventative." – Apex Pressure Ulcer Expert Witness

The consequences of omission: unplanned discharges and rapid readmissions

Despite ongoing concerns about mobility, weight loss, and blood abnormalities, the patient was discharged twice within two weeks. On both occasions, he returned to hospital with worsened clinical signs including confirmed pressure injuries.

Although discharge notes referenced family-provided arrangements such as a downstairs bed and community referrals, there was little evidence that nursing teams confirmed these safeguards were adequately in place. The rapid readmission following a fall and the identification of multiple pressure injuries underscored the failure of discharge planning aligned with pressure ulcer prevention principles.

Recommendations from a pressure ulcer expert witness

The expert opinion provided by Apex concluded that, had the risk been properly recognised and acted upon, the pressure injuries sustained would likely have been avoided. The nursing failings particularly in relation to Waterlow documentation, care planning, and post-discharge coordination fell below a reasonable standard.

These failings were not isolated incidents but signs of a broader systemic gap in applying pressure ulcer policy. Notably:

• Nurses failed to document how risk scores were calculated

• No consistent repositioning schedule was documented

• Comfort rounding did not include active skin inspection

• Risk assessment policy conflicted with what was actually used (Waterlow vs Trust tool)

The expert did not support defending the allegation of breach, citing inadequate pressure ulcer prevention protocols.

Need to instruct a pressure ulcer expert witness? Get in touch with us at info@apexexperts.co.uk, call us on 0203 633 2213 or visit our contact us page.