Case Study: How Missed Prevention Led to Avoidable Heel Pressure Damage

Pressure injury prevention is one of the most fundamental responsibilities in inpatient nursing care. When carried out consistently, it protects vulnerable patients from serious and avoidable harm. When it is fragmented or inconsistently applied, even patients identified as high risk can deteriorate quickly.

This anonymised case involves an elderly inpatient with multiple risk factors who developed a preventable heel pressure damage during a prolonged hospital stay. A senior pressure injury expert from Apex Experts was instructed to review the care delivered.

Background: A High Risk Patient From the Point of Admission

The patient, aged over 100, was admitted following a fall at home. She presented with several well recognised risk factors for pressure damage, including:

• Diabetes

• Extremely fragile skin

• Limited mobility

• Recent orthopaedic surgery

On admission, nursing staff completed a Waterlow assessment which placed her in the very high risk category. Despite this, the expert found that key clinical factors were omitted from the score, including her diabetes and history of recent surgery. A later recalculation increased the score significantly, highlighting initial inconsistencies in risk assessment.

From the outset, the patient required a robust pressure injury prevention plan with coordinated action across the multidisciplinary team. This did not occur.

Expert Findings: Repeated Failures in Pressure Injury Prevention

The expert identified multiple missed opportunities to prevent harm. Although early risk was acknowledged, interventions were inconsistent, poorly documented, or absent entirely.

Inadequate Risk Assessment and Reassessment

The patient was transferred between clinical areas without timely reassessment. Risk assessments were delayed, and when completed, they lacked precision.

The expert noted that although the Waterlow score still placed the patient at very high risk, the omissions demonstrated a lack of clinical attention to detail that shaped the rest of her care.

Fragmented SKIN Bundle Use

SKIN bundles were present within the notes but lacked:

• Narrative descriptions of skin condition

• Identification of red flags

• Evidence of escalating concerns

• Clear rationale for repositioning or equipment decisions

This left no clear picture of the patient’s pressure injury status across the admission.

Repositioning and Pressure Relief: Long Gaps and Missing Evidence

Hospital policy required 2-hourly repositioning for patients at very high risk. Yet the records showed prolonged undocumented periods, including gaps of five hours to more than thirteen hours without evidence of repositioning or offloading.

The expert considered these omissions to be inconsistent with acceptable practice for a patient of this age and risk profile. Specific failings included:

• No documented heel offloading

• Missing pressure care plans throughout the admission

• An airflow mattress being identified as needed but not provided

• Intermittent use of a pressure relief trough without documented rationale

• No TVN referral when early heel discolouration became apparent

In one documented period, the patient sat in a chair for more than ten hours with no recorded pressure relief.

Escalation and Early Damage Recognition

Signs of early heel damage were documented, yet there was no escalation to senior staff or referral to the Tissue Viability Nurse. The expert noted that early intervention at this stage could have prevented tissue breakdown.

Instead, the injury progressed to open tissue damage. The expert concluded that a coherent plan was never implemented, and the fragmented approach to care allowed the pressure injury to develop and deteriorate.

Systemic Issues Highlighted by the Expert

The expert concluded that the failings went beyond individual omissions. They reflected broader systemic issues in the management of frail inpatients with complex needs.

Key systemic concerns included:

• Lack of joined up care planning

• Missed opportunities for early prevention

• Over reliance on incomplete SKIN bundles

• Insufficient oversight of pressure care equipment

• Poor communication between clinical areas

Although staff completed various isolated tasks, there was no evidence of a coordinated approach to pressure injury prevention.

Expert Conclusion on the Heel Pressure Damage

The expert’s opinion was clear. Given the patient’s age, medical history, and presenting risks, the development of a heel pressure injury was avoidable. The absence of consistent repositioning, early offloading, a structured care plan, appropriate pressure relieving equipment and proper escalation of early damage all amounted to a failure to provide care that met accepted standards.

Taken together, these omissions represented a systemic nursing failure that materially contributed to the development of the heel pressure injury in this vulnerable patient.