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Pressure points: learning from Serious Case Reviews of failures of care and pressure ulcer problems in care homes

Jill Manthorpe (Social Care Workforce Research Unit, King’s College London, London, UK)
Stephen Martineau (Social Care Workforce Research Unit, King’s College London, London, UK)

The Journal of Adult Protection

ISSN: 1466-8203

Article publication date: 9 October 2017




Serious Case Reviews (SCRs, now Safeguarding Adults Reviews (SARs)) may be held at local level in England when a vulnerable adult dies or is harmed, and abuse or neglect is suspected, and there is cause for concern about multi-agency safeguarding practice. There has been no analysis of SCRs focussing on pressure ulcers. The purpose of this paper is to present findings from a documentary analysis of SCRs/SARs to investigate what recommendations are made about pressure ulcer prevention and treatment in a care home setting in the context of safeguarding. This analysis is presented in cognisance of the prevalence and risks of pressure ulcers among care home residents; and debates about the interface of care quality and safeguarding systems.


Identification of SCRs and SARs from England where the person who died or who was harmed had a pressure ulcer or its synonym. Narrative and textual analysis of documents summarising the reports was used to explore the Reviews’ observations and recommendations. The main themes were identified.


The authors located 18 relevant SCRs and 1 SAR covering pressure ulcer care in a care home setting. Most of these inquiries into practice, service communications and the events leading up to the death or harm of care home residents with pressure ulcers observed that there were failings in the care home, but also in the wider health and care systems. Overall, the reports reveal specific failings in multi-agency communication and in quality of care. Pressure ulcers featured in several SCRs, but it is problems and inadequacies with care and treatment that moved them to the safeguarding arena. The value of examining pressure ulcers as a key line of inquiry is that they are “visible” in the system, with consensus about what they are, how to measure them and what constitutes optimal care and treatment. In the new Care Act 2014 context they may continue to feature in safeguarding enquiries and investigations as they may be possible symptoms of system failures.

Research limitations/implications

Reviews vary in content, structure and accessibility making it hard to compare their approach, findings and recommendations. There are risks in drawing too many conclusions from the corpus of Reviews since these are not published in full and contexts have subsequently changed. However, this is the first analysis of these documents to take pressure ulcers as the focus and it offers valuable insights into care home practices amid other systems and professional activity.

Practical implications

This analysis highlights that it is not inevitably poor quality care in a care home that gives rise to pressure ulcers among residents. Several SCRs note problems in wider communications with healthcare providers and their engagement. Nonetheless, poor care quality and negligence were reported in some cases. Various policies have commented on the potential overlap between the raising of concerns about poor quality care and about safeguarding. These were highlighted prior to the Care Act 2014 although current policy views problems with pressure ulcers more as care quality and clinical concerns.

Social implications

The value of this documentary analysis is that it rests on real case examples and scrutiny at local level. Future research could consider the findings of SARs, similar documents from the rest of the UK, and international perspectives.


The value of having a set of documents about adult safeguarding is that they lend themselves to analysis and comparison. This first analysis to focus on pressure ulcers addresses wider considerations related to safeguarding policy and practice.



This study was undertaken as part of the Social Care Workforce Research Unit’s programme of research for the Department of Health’s Policy Research Programme. The views contained in this paper are those of the authors alone and should not be seen as necessarily reflecting the view of the Department of Health.


Manthorpe, J. and Martineau, S. (2017), "Pressure points: learning from Serious Case Reviews of failures of care and pressure ulcer problems in care homes", The Journal of Adult Protection, Vol. 19 No. 5, pp. 284-296.



Emerald Publishing Limited

Copyright © 2017, Emerald Publishing Limited

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