Importance of Care Plans in Preventing and Managing Pressure Ulcers

A Case Example

The patient in this case suffered a stroke and was admitted to hospital. After being discharged, a memory foam mattress was ordered for the patient, this was the wrong type of mattress. The patient was known to be at a high risk of getting pressure ulcers but was not referred to the District Nurses for pressure ulcer risk assessments.

The patient did not receive appropriate assessments until almost one month after discharge. Within this month the patient had developed grade/category three pressure ulcers Within the next month these pressure ulcers were necrotic. The patient died only two months later due to osteomyelitis, pressure ulcers and sepsis.

The main learning points from this review stem from the following events:

  • The wrong type of mattress was ordered for the patient when discharged.
  • The patient was not referred to the District Nurses for pressure ulcer risk assessments.
  • There was a delay in the pressure ulcers being identified, recorded or treated.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

  • Ensure that the correct mattress type is ordered when discharging patients. For patients who are bed bound or have very limited mobility an air mattress is required to reduce the risk of pressure ulcers. The wrong mattress in this case contributed to the development of pressure ulcers.

  • Ensuring that any at risk patients are referred to receive relevant assessments. This is more so recommended to patients who are being discharged as they will not be under constant care from practitioners. These relevant assessments should be detailed with the current condition of the patient and the urgency at which it should be completed.

  • Ensuring a care plan is in place when a patient is discharged in recommended, this should include instructions given to care providers at home. In this case, the Deceased’s partner and the carers should have been advised on the frequency and offloading of the patient’s lower limbs, what to look for on regular skin inspection, incontinence and their nutritional and fluid requirements. Carers should also be instructed on the signs and symptoms of pressure ulcers which may occur in at risk immobile patients. (NHS)

  • It is recommended that pressure ulcers are regularly checked for by carers and district nurses in order to actively begin treatment at the earliest point. When an ulcer is identified by a nurse, the patient should then be moved at least every four hours to prevent worsening as per NICE pressure ulcer guidance 2014/Quality Standard 2015.


It is recommended that patients who are discharged from hospital should have a care plan in place which covers all aspects of care, including a review of the type of mattress that should have and has been ordered. If the discharged patient is to be reviewed by District Nurses, any assessments which need to be made should be referred with a note of the urgency of said assessments. Included in this care plan should also be instructions fully explained and shown to family members and carers of the patient in order to prevent pressure ulcers and other potential complications.

TMLEP would like to highlight the importance of care plans being fully completed and in place before discharging a patient.