Introduction
Many people who are frail and have restricted mobility are at risk of developing ulcers on the points of their body which receive the most pressure. These are known as pressure ulcers, pressure sores, bed ulcers or ulcers. Pressure ulcers start with skin discolouration but if left untreated they can become very deep and infected, and in the worst cases they can be life threatening. With management and care, pressure ulcers can be avoided in most cases.
Pressure ulcers are primarily an issue for clinical investigation, rather than a safeguarding adults enquiry and should be referred to an appropriate health professional in the first instance. However, they can occur through neglect and/or omission of care (including self-neglect).
Deciding whether to refer to safeguarding adults procedures
The Department of Health and Social Care (DHSC) Safeguarding Adults Protocol: pressure ulcers and raising a safeguarding concern guidance provides a Safeguarding Decision Guide with six key questions. This will help to determine if a safeguarding referral should be made to the local authority.
The Safeguarding Decision Guide should be completed prior to making a safeguarding adults referral in relation to pressure ulcer concerns. If it is determined that a referral to safeguarding is required, the completed guide can then be attached to the referral (there is an option to upload documents at the end of the online referral form).
Key points from the protocol:
- The decision guide should be completed by a qualified member of staff who is a practising registered nurse (RN) with experience in wound management and not directly involved in the provision of care to the service user at the time the pressure ulcer developed. If it is not possible to meet this requirement, for example, due to staffing limitations or availability, the reason must be clearly documented, and the most appropriate available staff member with relevant expertise should complete the guide. In such cases, transparency in the rationale for the decision is essential, and steps should be taken to minimise any potential conflict of interest.
- The adult safeguarding decision guide should be completed immediately or within 48 hours of identifying the pressure ulcer of concern.
- Where the individual has been transferred into the care of the organisation it may not be possible to complete the decision guide. Contact should be made with the transferring organisation to ascertain if the decision guide has been completed or any other action taken. Following this, a decision should be made whether to raise a safeguarding adults concern with the local authority, in line with agreed local arrangements.
A one-page flowchart developed by Little Sisters of the Poor provides helpful guidance on the steps referrers need to take.
Safeguarding adult enquiries involving pressure ulcers
The Local Authority are responsible for coordinating any safeguarding adult enquiries. As part of these enquiries an organisation may be asked to complete an investigation. When doing so, the following points may be helpful to consider:
Patient history
• Include any factors associated with the patient’s behaviour that should be taken into consideration.
Medical history
• Does the patient have chronic disease which may impact on skin integrity? e.g. Rheumatoid Arthritis
• Is the patient receiving palliative care?
• Does the patient have any mental health problems which might impact on skin integrity? e.g. dementia / depression
• Were potential risks assessed and documented?
Monitoring of skin integrity
• Should the illness, behaviour or disability of the patient have reasonably required the monitoring of skin condition (where no monitoring has taken place prior to skin damage occurring)?
• Did the patient refuse monitoring? If so, did the patient have the mental capacity to refuse such monitoring?
• If monitoring was agreed, was the frequency of monitoring appropriate for the condition as presented at the time?
Expert advice on skin integrity
• Was appropriate assistance sought?
• Was advice provided? If so was it followed?
Care planning & implementation – skin integrity
• If expert advice was provided did it result in a care plan?
• Were all of the actions on the care plan implemented? If not, what were the reasons for not adhering to the care plan?
• Did the care plan include provision of specialist equipment?
• Was the specialist equipment provided in a timely manner?
• Was the specialist equipment used appropriately?
• Was the care plan revised within appropriate time scales?
Care provided in general (hygiene, continence, hydration, nutrition, medications)
• Does person have continence problems? If so are they being managed?
• Are skin hygiene needs being met? (including hair, nails and shaving)
• Has there been deterioration in physical appearance?
• Are oral health care needs being met?
• Does patient look emaciated or dehydrated?
• Is there evidence of intake monitoring (food and fluids)?
• Has patient lost weight recently? If so, is patient’s weight being monitored?
• Is patient receiving sedation? If so is the frequency and level of sedation appropriate?
• Does patient have pain? If so has it been assessed? Is it being managed appropriately?
Other possible contributory factors
• Has there been a recent change (or changes) in care setting?
• Does the patient have a history of falls? If so has this caused skin damage? Has the patient been on the floor for extended periods?
Local contacts
| Team | Contact details | |
|---|---|---|
| Safeguarding Adults Unit | Provide advice and guidance to professionals/volunteers from any agency on safeguarding adult matters. | Online Advice Request |
| Acute and Community Tissue Viability Team | Must be consulted for any category 3 or 4 pressure ulcers. | Email: nuth.tvn.community@nhs.net |
| Newcastle upon Tyne Hospitals Safeguarding Adults Team | Single point of contact for Newcastle upon Tyne Hospitals staff (including community staff) in relation to safeguarding adults. | Follow internal procedures for contact. |
Case studies/examples
These are made-up case examples which have been used for training and education purposes.
Frequently asked questions
Do I always need to submit a safeguarding adults referral if I am notifying the Care Quality Commission (CQC) of an injury as per Regulation 18?
No. There are different criteria for a safeguarding adults referral and Regulation 18 notification. However, in some circumstances both will be required.
Providers are required to notify CQC of injuries that include “the development after admission of a pressure sore of grade 3 or above that develops after the person has started to use the service.”
Safeguarding adults referrals should be made when the pressure ulcer/skin deterioration is felt to be linked to abuse or neglect. The grading of the pressure ulcer does not (on it’s own) determine whether a safeguarding adults referral is required. The completion of the Safeguarding Decision Guide will assist in making this decision.
What should I do if it is not feasible for the Safeguarding Decision Guide to be completed by a Registered Nurse and/or who has not had direct involvement in the adult’s care?
As per the guidance above, a pragmatic approach has been agreed in Newcastle. Other relevant professionals/staff members can complete the tool, including those who have had involvement in the adult’s care. The person completing the Safeguarding Decision Guide should remain as objective as possible and reasons why this requirement could not be met should be documented.
I am worried about my own pressure ulcer or that of a family member, what should I do?
If you’re concerned about your own pressure ulcer or that of a family member/friend, it’s crucial to seek immediate medical advice. Look for signs like redness, swelling, pus, or severe pain, and contact a GP or nurse, or use NHS 111 for urgent help. Early intervention is key to prevent the ulcer from worsening. If you or the person you are concerned about is receiving care (e.g. home care or a care/nursing home) you could also ask the care provider for help. If you believe the pressure ulcer occurred because of abuse or neglect you can report it via safeguarding adults procedures. You do not need to complete the pressure ulcer decision-guide. There is more information about pressure ulcers on the NHS website.
Further information
National Wound Care Strategy Programme (NWCSP) (resources moving to FutureNHS June 2025)