Peter Sudlow

1. 1. no referral to TVN during hospital stay

   “During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time.”

2. 2. no referral at grade 2

   “There was no referral to the TVN when the sore was categorised as a grade 2.”

3. 3. no referral at high Waterlow score

   “There was no referral to the TVN when the Waterlow score of the deceased increased to 17.”

4. 4. no referral at Grade 4

   “There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19.”

5. 5. lack of referral criteria

   “There was no clear guidance as to when and in what circumstances a referral to the TVN should be made.”

6. 6. no referral guidance for high-risk patients

   “The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores.”

No published response was found on judiciary.uk.