How a Pressure Ulcer Litigation Expert Witness Assessed Missed Risk Assessments and Wound Progression
- Apex Experts
- Sep 2
- 2 min read
When pressure ulcer care plans are inconsistent, patients suffer
This case involves a medically complex elderly inpatient who developed multiple avoidable pressure injuries, including to the sacrum and right hip. Despite the presence of national guidelines and local SSKIN protocols, key documentation was inconsistent, and treatment plans were not followed.
An Apex pressure ulcer litigation expert witness was instructed to assess whether nursing care breached the expected standard. The expert identified that failures in early risk identification, poor execution of care bundles, and non-compliance with Tissue Viability Nurse (TVN) instructions all contributed to significant skin breakdown.
Why the pressure ulcer litigation expert witness found care delays indefensible
Upon transfer to a new ward, the patient did not have a Waterlow risk assessment or high-risk SSKIN bundle initiated. Wound grading was inconsistent, the care plan lacked continuity, and the TVN’s instructions were not followed across multiple days.
Key clinical failings included:
Delayed initiation of a SSKIN bundle on transfer
Discrepancies in grading the same wound (grade 2 vs grade 3)
Missed signs of developing hip pressure damage
No documented escalation when wounds became unstageable
A care plan that was written but not enacted
“Pressure damage was entirely foreseeable. The failure to act on TVN advice and complete SSKIN documentation consistently fell well below a defensible nursing standard.” — Apex Pressure Ulcer Litigation Expert Witness
What a pressure ulcer litigation expert witness expects from ward teams
When a patient is high-risk and immobile, the nursing team is expected to:
Complete a Waterlow score within 6 hours of transfer
Initiate a high-risk SSKIN bundle with daily updates
Accurately document wound condition and grading
Implement care plans developed by the TVN
Re-refer if wound deterioration occurs or if escalation is needed
In this case, by the time the patient was re-reviewed by the TVN, both the sacrum and hip ulcers had deteriorated to unstageable. This marked a clear failure to monitor and intervene.
How documentation gaps undermine both care and legal defence
Beyond clinical implications, the inconsistent wound grading, missing inspection records, and lack of follow-through weakened the Trust’s position in this claim. The expert’s review confirmed that these systemic oversights directly contributed to avoidable deterioration and potentially accelerated the patient’s overall decline.
Such cases highlight why consistent execution of care plans and policy compliance are as crucial for litigation defence as they are for patient safety.