This guidance sets out the approach to pressure ulcers and safeguarding adults, including how organisations should respond and when a safeguarding concern should be considered.
This guidance updates the previous national and local standard protocol advising and supporting organisations in regard to pressure ulcers and the decision-making process as to whether a safeguarding concern should be raised with the local authority in order for them to determine if a section 42 safeguarding enquiry is required.
Terminology used in different settings varies – the terms patient, resident, service user and clients are all often used. For the purpose of this guidance the term individual or person will be used throughout.
Pressure ulcers are a key indicator of the quality and experience of care. Those at risk of pressure ulcers are cared for in many different settings across health and social care including their own home. We know that many pressure ulcers are preventable and when they occur, they can have a profound impact on the individual’s overall wellbeing affecting many aspects of their life and can be both painful and debilitating.
It is important to recognise some people who develop pressure ulcers are not in receipt of healthcare services but receive care from family, friends or paid carers. Therefore, it is also vital that carers receive training in the prevention and signs of developing pressure ulcers, as well as how and when to escalate it to relevant health services.
The principles of well-being and safeguarding in the Care Act 2014 requires that all agencies work together to achieve the best outcomes for the individual. It clearly lays out the duties of relevant partners to cooperate, including (but not limited to) local authorities and NHS bodies. This approach is a person-centred model that begins with the individual at the centre of the concerns and fully involves them or their representative as appropriate. It is important that the response to the presence of pressure ulcers involves the individual and their family, explaining the concerns and seeking their views.
The aim of this guidance is to provide a locally agreed response in line with the overarching national framework Pressure ulcers: how to safeguard adults – GOV.UK (June 2025) identifying pressure ulcers as primarily an issue for clinical investigation rather than a safeguarding enquiry led by the local authority. Indicators to help decide when a pressure ulcer case may additionally need a safeguarding enquiry are included.
While the operational responsibility for investigating pressure ulcers is largely health led, the Safeguarding Adults Board (SAB) has a strategic interest in the prevalence of pressure ulcers across the sectors as a potential indicator of the quality of care. The SAB may want to consider reporting on the prevalence of pressure ulcers as part of quality assurance processes.
Where a pressure ulcer is one of a number of safeguarding concerns in relation to an individual or setting (e.g. concerns which may be considered as organisational abuse) then there should be a multi-agency approach coordinated by the local authority, with the relevant health partner taking the lead for the clinical investigation.
3.1 Pressure ulcers may occur as a result of neglect or acts of omission. Neglect may involve the deliberate withholding or unintentional failure of a paid, or unpaid, carer to provide appropriate and adequate care and support. Neglect and acts of omission include:
• ignoring medical, emotional or physical care needs
• failure to deliver appropriate healthcare and support including provision of equipment and training
• the withholding of the necessities of life, such as nutrition and hydration, comfort and warmth, appropriate medication, and emotional well-being
In some instances, this is highly likely to result in significant preventable skin damage.
3.2 Unintentional neglect may be due to an unpaid carer struggling to provide care or not knowing the signs of developing pressure ulcers or why the person they care for is at risk. An appropriate response would be to review the care and ensure that the carer has the support and equipment to care safely, this may include providing a care package for the individual. In these circumstances it can be highly distressing to talk to carers about abuse and neglect, particularly where they have been dedicated in providing care but have not been given advice and support to prevent pressure ulcers. A sensitive planned approach to address the concerns in these situations is advised as best practice.
3.3 Where skin damage is identified as a result of pressure i.e. a pressure ulcer, it must be raised as a concern within an organisation; and if health services are not already involved then in discussion with the individual, appropriate actions should be taken to refer the person to health services.
3.4 A clinician should assess and document the cause of the pressure ulcer and recommend measures to allow healing to take place and prevent any recurrence. It is recognised that not all pressure ulcers can be prevented and the risk factors for each person should be looked at on an individual basis and an appropriate care plan put in place that is regularly and frequently reviewed.
3.5 If the individual lacks capacity to consent to some or all of the care plan it must be clearly evidenced that care is being provided in their best interests in line with the principles of the Mental Capacity Act 2005.
3.6 When advising an individual who has capacity about self-care and prevention of pressure ulcers, it is important to establish that the person:- (i) has understood the advice; (ii) can put the advice into practice and chooses to do so; (iii) has any necessary equipment and knows how to use it; and (iv) understands the implications of not following the advice.
3.7 Where an individual chooses not to agree to follow advice, compromise and alternatives must be discussed and agreed upon if possible. Where an individual chooses not to follow any or some of the advice, an agreement to revisit the conversation must be made. The reasons for non-concordance should be explored sensitively utilising a trauma-informed approach https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice
3.8 Where it appears that the individual is neglectful in caring for themselves or their environment, staff should escalate their concerns and seek further advice through a safeguarding/self-neglect route with the local authority.
3.9 Where an individual being cared for in a hospital or care home (or their own home where a care package is already in place) develops severe damage indicated as multiple pressure ulcers of category 2 or a single pressure ulcer of category 3 or 4 (including unstageable and deep tissue injury) an incident should be raised immediately and managed as per local organisational policy.
3.10 Duty of Candour – it is a legal requirement for health and social care organisations to inform an individual (and their families) when they have been harmed as a result of the care or treatment they have received or have not received.
3.11 The Adult Safeguarding Decision Guide for individuals with severe pressure ulcers (appendix one) should be used as a tool to determine whether a safeguarding concern is raised to the local authority. The decision guide should be completed by the organisation where the pressure ulcer developed by a nurse or qualified member of staff with experience in wound management and not directly involved in the provision of care to the individual at the time the pressure ulcer developed. This does not have to be a tissue viability nurse. Where the person lives in a residential care setting this will be a District/Community Nurse. Where the decision guide indicates a total score of 15 or more a safeguarding concern should be considered. Advice should be sought from the organisation’s safeguarding lead or local authority safeguarding team if the decision to submit a concern is not clear.
3.12 Making Safeguarding Personal – the individual (or their family/advocate) should be made aware of a decision to raise a safeguarding concern and their consent sought to be involved in any further enquiry. Further enquiry work should then consider the desired outcomes of the individual. If consent is not given, then a multi-agency enquiry may still proceed in the wider public interest where the concerns involve the actions or omissions of a registered care provider; or an informal carer whose actions or inactions may be regarded as wilful.
3.13 If the individual lacks capacity to consent to or be involved in a section 42 enquiry then a family member/close friend may be asked to provide information about the person’s views; choices and wishes. Where there is no family/friend involvement in care then referral to advocacy services may need to be considered.
3.14 The decision as to whether there should be a section 42 enquiry will be taken by the local authority, informed by a clinical view. A summary of the decision should be recorded and shared with all agencies involved.
3.15 Where an internal investigation is required it should be completed by an appropriate manager responsible for the care delivery when the pressure ulcer developed e.g. the district nurse team leader; hospital ward manager; nursing home manager, in line with local organisational policies. The investigator should have the appropriate clinical skills and experience in the prevention and management of pressure ulcers. Any learning identified should be shared with the individual themselves and with the people caring for them, to reduce the risk of future harm occurring.
3.16 If a safeguarding concern is raised to the local authority without reference to the Adult Safeguarding Decision Guide, then following a conversation with the referrer/organisation involved they may send the guide to the organisation to be used as part of clinical enquiry and any subsequent section 42 enquiry.
References
- Care Act 2014 Care Act 2014
- Care and Support Statutory Guidance (updated July 2025) Care Act statutory guidance
- Mental Capacity Act 2005 Mental Capacity Act
- Mental Capacity Act 2005 Code of Practice 2007 Mental-capacity-act-code-of-practice.pdf
- Dept of Health and Social Care (June 2025) Pressure ulcers: how to safeguard adults – GOV.UK
- Office for Health Improvement and Disparities (November 2022) Trauma Informed Practice
Appendix One
Adult Safeguarding Decision Guide for Individuals with Severe Pressure Ulcers
This decision guide should be used as a tool to determine whether a safeguarding concern should be raised to the local authority.
The decision guide should be completed by the organisation where the pressure ulcer developed by a nurse or qualified member of staff with experience in wound management and who is not directly involved in the provision of care to the individual at the time the pressure ulcer developed. This does not have to be a tissue viability nurse.
Where the person lives in a residential care setting this will be a District/Community Nurse.
Where the decision guide indicates a total score of 15 or more, a safeguarding concern should be considered. Advice should be sought from the organisation’s safeguarding lead or local authority safeguarding team if the decision to submit a concern is not clear.
Question 1
Has the pressure ulcer deteriorated to category 3; 4; is unstageable or a deep tissue injury; or are there multiple category 2 pressure ulcers from healthy unbroken skin since the last assessment?
- Yes = 5
- No = 0
Evidence / comments:
e.g. evidence of redness or skin breaks with no evidence of provision of repositioning or pressure relieving devices provided
Question 2
Has there been recent change in person’s clinical condition that is within hours/days that could have contributed to skin damage?
- Yes = 0
- No = 5
Evidence / comments:
e.g. infection, fever, anaemia, end of life care, critical illness, weight-loss, changes in mobility / moving and handling etc
Question 3
Was there a pressure ulcer risk assessment or reassessment with appropriate pressure ulcer care plan in place and documented – in line with the organisation’s policy and guidance?
- Yes = 0
- Partial = 5
- No = 15
Evidence / comments:
State date of assessment, risk tool used and score or risk level.
State elements of care plan that are in place or what should be in place and isn’t.
Question 4
Is there a concern that the pressure ulcer developed as a result of the informal carer wilfully ignoring or preventing access to care or services?
- Yes = 15
- No = 0
Question 5
Is the level of damage to skin consistent with the patient’s risk status for pressure ulcer development?
- Yes – skin damage is less severe than risk indicates = 0
- No – skin damage is more severe than risk indicates = 10
Evidence / comments:
State tool used and score/risk rating e.g. Braden, Waterlow etc.
Question 6 – Capacity and consent
Answer (a) if the person has capacity to consent to all elements of the care plan.
Answer (b) if the person has been assessed as not having capacity to consent to some or any of the care plan.
(a) Capacity
Were the risks and benefits explained and understood by the person?
Was a plan of care agreed in line with shared decision making and has the person chosen to follow the relevant aspects of the plan?
- Person has followed care plan, and local policies to support shared decision making have been followed = 0
- Person followed some aspects of the care plan but not all = 3
- Person has not followed care plan or not given information to enable them to make an informed choice, or an opportunity to discuss reasons for not following the agreed plan and alter the plan accordingly has not been taken = 5
(b) Lacks capacity
Was appropriate care undertaken in the person’s best interests, following the best interests checklist in the Mental Capacity Act Code of Practice?
Is this supported by documentation, e.g. capacity and best interest statements and record of care delivered?
- Yes = 0
- Partial = 5
- No = 10
Total score and outcome
A score of 15 or over indicates a safeguarding concern should be considered.
Contact your organisation’s safeguarding lead or the local authority safeguarding team for advice if the decision to submit a concern is not clear.
Total score: (record locally)
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