Cecilia Edwards

“On 12 February 2020, a district nurse assessed Ms [name redacted]' elbow as a category 3 pressure ulcer, which should have prompted an immediate referral to the tissue viability nurse. However, no such referral was made, either by the attending nurse; the district nurses who visited twice a week over the next seven months; the frequent care plan reviewers; or the shift co- ordinator until 22 September 2020.”