5.11 Pressure Ulcers – Safeguarding Adults Protocol

1. Introduction

This chapter summarises the updated protocol on pressure ulcers and safeguarding adults published by the Department of Health and Social Care in January 2024. See Safeguarding Adults Protocol: Pressure Ulcers and Raising a Safeguarding Concern (DHSC) for the full protocol and accompanying assessment tools.

2. What is the Protocol For?

The protocol describes the process to be followed when it is identified that an adult has a pressure ulcer, including how to assess if a safeguarding concern should be raised with the local authority.

The protocol – which was first published in 2018 – has been reviewed and updated due to increased concern about pressure ulcers in all settings, and because there has been a lack of clarity about when concerns about pressure ulcers should be raised with the local authority adult safeguarding team, for a possible section 42 safeguarding enquiry.

The updated protocol also aims to raise awareness of pressure ulcers across the social care workforce, so that more can be done to prevent their occurrence and enable a speedy response. It makes it clear that – in most cases – the appropriate response to pressure ulcers will be led by health practitioners and will not involve adult safeguarding processes.

The protocol is accompanied by an adult safeguarding decisions guide which should be completed by a registered nurse when severe damage from pressure ulcers is identified. If responses to questions in the guide give a total score of more than 15, then concerns should be shared with the local authority adult safeguarding team.

3. What are Pressure Ulcers?

Pressure ulcers (also called pressure sores or bed sores) are an injury that break down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They usually form on bony parts of the body, such as the heels, elbows, hips and tailbone (coccyx, at the base of the spine).

Signs of a pressure ulcer include:

• discoloured patches of skin that do not change colour when pressed – such patches are usually red on white skin, or purple or blue on black or brown skin.
• a patch of skin that feels warm, spongy or hard.
• pain or itchiness in the affected area of skin.

People are at more risk of developing pressure ulcers if they:

• have problems moving / are not very mobile.
• have had a pressure ulcer before.
• have been seriously ill in intensive care or have recently had surgery.
• are underweight.
• have swollen, sweaty or broken skin.
• have poor circulation or fragile skin.
• have problems feeling sensation or pain.

4. Preventing Pressure Ulcers

Pressure ulcers cause pain and distress to adults and can be upsetting for their families, but most can be prevented. Preventing pressure ulcers is the responsibility of everyone working with adults who have care and support needs, as many of those who are at risk of pressure ulcers will be receiving services and support from staff working across the social care sector.

To prevent pressure ulcers, all health and social care practitioners need to be able to recognise the risk factors for developing pressure ulcers and be able to take appropriate, speedy action if they identify skin damage.

Assessments, including risk assessments, should look at the likelihood of pressure ulcers developing and describe actions that will be taken to prevent them. This applies to adults living at home as well in registered care home settings.

5. What to do When a Pressure Ulcer is Identified

• Involve the adult and their family / carers – where there is concern that a pressure ulcer has developed, it should firstly be discussed with the adult and their family. Responses to pressure ulcers should always have the person at the centre and fully involve them (or their representative) and family.
• Refer for treatment – concerns about a possible pressure ulcer should be referred to appropriate healthcare services who will be able to provide treatment and put a plan in place to prevent further damage to the skin.
• Health led response – responding to pressure ulcers will mainly be an issue for health practitioners. The protocol is clear that it is not appropriate or necessary for adults with pressure ulcers to be routinely referred to the local authority safeguarding adults team.

6. When to Raise a Safeguarding Concern

Most adults with pressure ulcers will not require a safeguarding referral / safeguarding response. The appropriate response will be interventions led by health professionals.

However, the protocol requires that the adult safeguarding decision guide is completed when an adult has ‘severe’ damage from pressure ulcers. Using the guidance in this way provides a standardised method for assessing whether it is appropriate for concerns to be shared with the local authority adult safeguarding team.

Within 48 hours of identifying a pressure ulcer which is classed as ‘severe damage’, the adult safeguarding decisions guide should be completed by a registered nurse with experience in wound management. The nurse completing the assessment should not be directly involved with the care of the adult.

The safeguarding adult decision guide contains six questions. Responses to these questions give an initial score which can be used to help inform decision making about whether to escalate safeguarding concerns. The threshold for raising a concern with the local authority is a score of 15 or above – but the score should be used alongside professional judgement.

6.1 Assessment score and next steps

If the decision guide score is 15 or higher (which is then a concern for safeguarding), then the protocol requires the following action to be taken:

• discuss with the person, family and / or carers that there are safeguarding concerns, explaining why and that a safeguarding enquiry will be raised.
• refer to the local authority, with completed safeguarding pressure ulcer decision guide documentation;
• follow local pressure ulcer reporting and investigating processes.
• record the decision in the person’s case records.

If the decision guide score is under 15, then the follow action is required:

• discuss with the person, family and / or carers and explain reason why it is not being referred for a safeguarding enquiry.
• explain why it does not meet criteria for raising a safeguarding concern with the local authority but stress the actions which will be taken to treat the ulcer and prevent any further skin damage.
• action any other recommendations identified and put preventative or management measures in place.
• follow local pressure ulcer reporting and health investigation processes.
• record the decision in the person’s record.

7. Further Reading

7.1 Relevant information

Safeguarding adults protocol: pressure ulcers and raising a safeguarding concern (Department of Health and Social Care)