When is it a social worker’s job to investigate pressure ulcers?

A debate about pressure ulcers highlights the contested issue of adult safeguarding's responsibilities in relation to poor care

Working with health
Photo: Burger Phanie Rex Features

Who would have thought that pressure ulcers would be one of the most contentious issues at Community Care’s conference on prevention in adult safeguarding this week?

The topic was raised by the first speaker, Claire Crawley, senior policy manager in adult safeguarding at the Department of Health, who, while outlining what we can expect in the imminent Care Act guidance, said: “Clinical issues remain clinical issues [rather than a safeguarding issue]. If I hear one more conference highlighting pressure ulcers as a safeguarding issue, I’ll shoot myself!”

Her comment sparked a debate that continued throughout the day about how far social workers intervene in cases of poor care in a safeguarding capacity.

In the question and answer session after Crawley’s presentation, one delegate queried her stance, questioning whether ulcers were purely clinical, however they occur. He argued that, as a patient safety issue, surely ulcers could become a safeguarding issue: if a plan is in place to prevent and manage ulcers and this isn’t followed through negligence then why is it not a safeguarding matter?

Crawley’s response was that ulcers were unlikely to lead to a safeguarding enquiry – as set out in section 42 of the Care Act – apart from in rare instances where actual abuse is present. However, this didn’t dispel some people’s apparent uneasiness at pushing the issue out of social workers’ safeguarding remit.

Paul Bedwell, business manager for the Essex safeguarding adults board, summed up the potential difficulties ahead for social workers acting in line with the new Care Act guidance when he said that there was a question around which alerts were about safeguarding and which were about quality of care issues. “There’s a fine line between quality of care and neglect, and it’s hard to define.”

Perhaps social workers and local authorities should take heart from Hertfordshire’s experience. The county moved away from social care staff having to investigate pressure ulcers through safeguarding because social workers “were on their knees” with the volume of referrals they were dealing with, according to Tracey Cooper, head of adult safeguarding at Herts Valleys Clinical Commissioning Group and NHS East and North Hertfordshire Clinical Commissioning Group.

Health and social care staff have been armed with specific guidance on how to make a decision about whether to refer an ulcer to adult safeguarding; a five-step procedure for determining if a pressure ulcer is due to neglect; and a screening tool. Now, if a pressure ulcer is believed to have been caused by neglect it is reported as an adult safeguarding alert; but, in other instances, the CCG as the commissioner investigates and providers (and GPs) are held to account.

The CCG has a range of sanctions it can use such as contract levers, including financial ones, and at the end of the day no provider wants that sort of bad publicity. The new approach is having a positive effect: in December 2013, East and North Hertfordshire NHS Trust had one month without a single, avoidable, hospital-acquired pressure ulcer in patients – the first time this has been achieved across the whole trust.

According to the Stop the Pressure campaign, 700,000 people are affected by pressure ulcers each year and each ulcer adds additional costs of care of over £4,000; 95% of ulcers are preventable using the five-step model  SSKIN.

Social workers have enough to deal with when it comes to adult safeguarding, perhaps it’s time to take the pressure off and take heed of the Department of Health’s view that unless there is evidence that an ulcer is caused by neglect or abuse, it is a health concern.

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18 Responses to When is it a social worker’s job to investigate pressure ulcers?

  1. Gary SPENCER-HUMPHREY October 11, 2014 at 7:00 pm #

    Surely an omissions can be abuse, so I would be uncomfortable saying in general this falls short of abuse.

  2. Edna October 12, 2014 at 11:21 am #

    This article confirms what is happening in adult social work. In order to validate their work and be seen as equal to child protection workers, social workers are working outside clear boundaries (or rather developing a lack of boundaries) in adult social work to make judgments on issues which are clinical and complex and beyond their experience/ knowledge..

    I have a lot of experience of pressure ulcers arising from different causes, it is simplistic in the extreme to assume that they always arise from poor care / neglect. This confirms how badly undertaken much of adult safeguarding is with assumptions and judgments being made of matters outside of social work knowledge base / experience.

    It is a fact that pressure ulcers may easily occur with bed bound elder patients when in hospital if relevant preventative measures are not taken and staff are not vigilant (staff shortages in the NHS at weekends create problems as I have observed).

    In the community, care agency / nursing-care home staff may be less than vigilant in the level of care required for clients who are non mobile. They fail to notice pressure areas or skin damage, or notice too late when damage has increased; this is not uncommon (personal experience). These staff and their managers will hide their neglectful/ unskilled/ inadequate care work. Some are so bad they will project blame onto others to protect themselves.

    Social services staff rely on these agency services and commission them, they are not impartial players where safeguarding investigations are undertake when their own contracted provision is involved in neglectful poor care. They do not ‘police’ care agencies / homes in the way they do informal carers who may be worn out and unsupported so being exhausted may overlook by mistake.

    The CQC too is useless and always has been- their inability to put comments /complaints sent about agencies on their website so families can themselves judge providers is the proof.

    The danger to society and the public is clear is social workers go beyond their abilities and knowledge to push safeguarding as a career path- This explains why they are the only ones requesting just about everything ‘under the sun’ come under their safeguarding remit, whether adults ‘being protected’ would agree. This must stop.

  3. WindyMiller October 12, 2014 at 12:28 pm #

    How will CCGs use sanctions when in the majority of instances, they have not commissioned any provision?

    • Edna October 13, 2014 at 10:45 am #

      That is not a social work issue, but for the NHS to resolve. Creating jobs for social workers is not the aim of safeguarding work- but by the way TCSW behaves and over zealous social work is practised you would think otherwise.

  4. Gary FitzGerald October 13, 2014 at 2:04 pm #

    It is really worrying the way complex issues, which can have such serious consequences for people in very vulnerable positions, are being simplified by the Department of Health, while the experiences of Adult Safeguarding practitioners are being ignored. Rather than be flippant about the issue, it might be more productive for the DH to initiate some serious discussions, and produce better guidance than we’ve seen so far, to help practitioners address these issues.

    The fact is that pressure damage may be indicative of clinical negligence, and this would fall within the remit of adult safeguarding wherever it occurred. So, the suggestion that ‘ulcers were unlikely to lead to a safeguarding enquiry apart from in rare instances where actual abuse is present’, is questionable on two levels. Firstly, the DH cannot legitimately refer to ‘rare instances’, unless they can point to empirical evidence to support this conclusion (and I’d be very pleased to see it). And secondly, because section 42 of the Care Act is about enquiring and not reaching advance conclusions. Consequently, the advice that ‘unless there is evidence that an ulcer is caused by neglect or abuse, it is a health concern’, therefore comes from the chicken and egg world. How do you know unless you enquire? And, if that enquiry is to be delegated, then those processes must be transparent and provide public assurance that institutional abuses are not being just ‘covered up’ internally or ignored.

    There is no doubt that adult safeguarding is under pressure, but the answer is not to splinter the process but to instead (a) sufficiently resource it and (b) develop the tools to ensure it operates appropriately. And in that context, perhaps the Herts model is worth exploring if it meets the above transparency criteria. But the purpose would have to be about identifying and addressing the cause of the pressure ulcer, not trying to triage it away from adult safeguarding simply to avoid costs or workload. There was a very good reason why No Secrets encouraged a multi-agency approach. Perhaps people need to be reminded of that.

  5. Stephen James October 14, 2014 at 8:16 am #

    This over simplification of what is often quite a complex area is indeed a concern to me also. We are still having to navigate a pathway through differing language/terminology within the NHS and local authorities, which has not been addressed with the Care Act revisions. The comments expressed by Claire Crawley might be well intentioned, but they do not help to move the debate forwards, and actually only serve to widen the gap between safeguarding practice in the NHS and elsewhere by reinforcing a two tier system. I am not advocating that every pressure ulcer is a safeguarding issue, but surely until you have made certain determinations you cannot know if it needs to be addressed as such or not. By letting the NHS manage this ‘in house’ is simply not consistent with the guidance being provided elsewhere re making enquiries, and serves to reinforce the ‘protection’ that is offered to the NHS in adult safeguarding processes. Another concern arising from this worrying development is that it effectively makes it even more difficult for adult safeguarding boards to hold NHS bodies to account and to receive appropriate assurances, if that were not difficult enough!

  6. Steve Clay October 14, 2014 at 8:39 am #

    Edna

    I cannot agree.

    I have used a line of your reply…”These staff and their managers will hide their neglectful/ unskilled/ inadequate care work.” to demonstrate why.

    Surely a neglectful workforce resulting in pressure damage falls bang in the middle of safeguarding? How can it not…

    Pressure damage has occured due to neglect…its simple

    • Edna October 14, 2014 at 12:33 pm #

      Steve and others

      You are missing the point- adult services commissions rock bottom care to save money. There are no adequate educational / linguistic standards of training required for care work and these commissioned care agencies hide their / abusive neglectful work – even their manager/ owners, in all number of ways.

      I have yet to see a social worker with the skills of seriously ‘weeding out’ these ‘bad guns’. Why? inherent conflict of interest because your departments cannot afford the ones that actually care enough to train and pay their workers to the standards expected.

      This leaves vulnerable people at risk. But I also re-iterate from actual experience and a knowledge base I see no evidence of in the responses here, that pressure ulcers / wounds are complex and the average social worker will be unable ( from much experience I have of them) to unravel matters without actually causing unnecessary problems in addition. Social work causes harm too as practised by so called ‘safeguarding zealots’..

      The second point is ‘safeguarding practitioners’ are not experts, it is a new industry, but clearly wish to create a career path on this premise. Unfortunately for social services / its staff the public are increasingly aware of this and elders (like myself) fear social work interventions more than being abused. I can sue the NHS- I cannot social services when harm is caused. This alone will affect the public view.

      Most people posting here have ‘vested ‘job’ interests’ and I have not been happy with Action on Elder Abuse when matters have been brought to their attention. The safeguarding industry does not need any protection or growth, vulnerable elders do and this will rely on unpaid ‘whistleblowers’- often ignored by SS/ police.

      • Gary FitzGerald October 14, 2014 at 7:48 pm #

        To the Moderator: I omitted a word in one sentence, which made a nonsense of the intent. Hence re-submitting this comment. My apologies.

        With respect Edna, we are not missing the point. It is no more accurate to say that all care work/workers are bad, untrained or incompetent people than it is to say that all clinicians/doctors/nurses get it right. The history and catalogue of neglect and abuses in the NHS stretches from mid-Staffordshire all the way back to Rowan ward in Manchester and beyond. And this is despite the apparent educational standards of training that you understandably value so highly.

        Equally, while we accept, and lobby for, the need to better invest in the training and support of adult safeguarding staff it is quite wrong to suggest that ‘all’ social workers are poor or are simply trying to make careers out of this issue. There are many who work far beyond what is reasonably expected because they genuinely care about what they are doing. And there are many who have tremendous expertise, developed over more than a decade in this work, which really should not be dismissed so lightly.

        Professor Gerry Bennett, who specialised in wound care and pressure ulcers once observed that guidelines for patients fail to indicate that the majority of pressure ulcers are preventable, should not have occurred, and can constitute neglect. The issue here is about how and in what manner the root cause of a pressure ulcer is identified and what steps are taken to prevent reoccurrence. It is also about ensuring that practices that are neglectful or abusive are not internalised or institutionalised, something that you profess happens in the community but appear reluctant to acknowledge happens in the NHS. The fact is that any process that either assumes that all pressure ulcers are a consequence of neglect, or conversely proposes that none of them are, must be flawed.

        Adult Safeguarding is based on a multi-agency and multi-disciplinary approach, which means that the process should not rely exclusively on the expertise or knowledge of a single social worker. This is the only logical approach to address both abusive practices in care provision in the community and abusive practices in heath care provision in the NHS. We do not suggest that the system is perfect, and we fully intend to continue seeking improvements. But it remains the right approach.

        We do of course regret that, whatever experiences you have had, they have led you to conclude that ‘vested job interests’ are the only motivator for people working in this area. Human Beings are more complex than that, and many are actually motivated by their own personal experiences, values in life, and a genuine concern for others.

        • Edna October 15, 2014 at 11:59 am #

          I used to think that dehydration in the cared for elderly was due to negligence, because like the one professor you have quoted (there are other pressure ulcer experts nationally and internationally) you accept this one view which supports your work.

          I since have found research which indicates that dehydration in nursing homes etc. and ensuring morbidities and death in the elderly are misinterpreted as due to neglect when the matters are very much more complex.

          I have a relevant background / experience, unlike those posting here. I undertake primary health research and read clinical papers and comprehend (doctors have a hard time with me indeed- but I have never been able to have the same equal relationship with any social worker who are secretive and develop ‘opinions’ to wield power).

          • Gary FitzGerald October 15, 2014 at 2:19 pm #

            Hello Edna, I could direct you to other clinicians, who share similar views about the potential for the root causes of many pressure ulcers to be neglect. And I could point out the number of clinicians and others who have worked with us. But that really is not the point, and I suspect you would be equally dismissive even if I were to do so.

            As I previously indicated, any process that either assumes that all pressure ulcers are a consequence of neglect, or conversely proposes that none of them are, must be flawed. And any assumption that categorises groups of people/workers as all bad or all good, is equally flawed.

            The Care Act 2014 has placed a legal duty on local authorities to inquire, or cause an inquiry, where abuse is suspected. It did not exempt the NHS, or issues like pressure ulcers, from that duty. Such an inquiry should identify the root cause of a pressure ulcer, and if that indicates abuse or neglect, then adult safeguarding processes should be triggered. It really is as straightforward as that.

        • Edna October 16, 2014 at 10:10 am #

          Gary Fitzgerald- a response to your 15th October reply.

          It is very clear that no one here has much knowledge of medical / health research (? or any primary research or complex meta reviews in science / medicine). If you did you would better understand my response.

  7. Keith M Lewin October 14, 2014 at 2:41 pm #

    The view expressed by Ms Crawley must, in my respectful view, be wrong in principle.

    I accept that not all pressure ulcers are the result of neglect; however, very many are. I am told by those with clinical knowlege (I have none) that just about all pressure ulcers can be avoided provided both great care is taken, and appropriate equipment is used.

    That being the case, the starting point should perhaps be to investigate.

    If I am wrong, what would be the view if the majority of people being cared for in a particular setting developed pressure ulcers?

    Would Ms Crawley have us believe that to be merely a case of bad luck?

    • Edna October 14, 2014 at 7:00 pm #

      If the majority of people developed pressure ulcers in a particular setting it would be the up to those who care enough (whistle blowers) to raise alarm to the CQC / chief executive / press etc. It is far beyond individual social work teams expertise / ‘safeguarding’ experise or ability to effect the actions needed.

  8. Keith M Lewin October 15, 2014 at 9:56 am #

    In response to Edna @ 7pm 14.10.2014…

    I am pleased that, at least, there is a level of debate around these issues. It seems to me that may not the case with the likes of Dept of Health.

    I really can’t agree with you that the state of care delivery, in particular, possible ‘negligent care’ should be the sole responsibility of whistleblowers. If that is to be the case what role for safeguarding?

    I imagine that the public would rightly expect that safeguarding play a central role.

    One is not contemplating a situation of differing professional opinion, rather a situation in which people’s health and well-being can be seriously and severely undermined – possibly to the point of causing or contributing to a person’s death.

    Do we really need more avoidable pain and death before society acts?

    For me, safeguarding has and should play a central role.

    • Edna October 15, 2014 at 10:34 am #

      In response to Keith @ 9.56am

      ‘possible negligent care’ is a subjective concept and opinions will vary even with health professionals as to whether in a particular case the pressure ulcers) were preventable.

      It is my experience, and confirmed by the responses here, that much of social work is nowadsays is ‘suspicion based’ and far from an open minded in approach, involving social workers in matters outside their ‘training / knowledge base’ only leads to harm.

      If some in society expect safeguarding, many many do not like local authority social services- I have never heard compliments in 4 decades of professional and personal involvement).

      I know for a fact that in domiciliary / residential care establishments too many people are not properly / adequately monitored in regards to their needs for care. Yet social workers I have found ignore this to place clients (who die prematurely) in said places. Especially if these people have assets to pay for the care or it is cheaper than the amount of home care required for others. The public are becoming too aware of this and I think safeguarding is getting a very bad name, The evidence is in the public response to ‘powers of entry’ for social workers in the recent DoH consultation.

      Elders ( and this includes just about every elder I personally know) do not want interventions unless they seek it, (often carers have hard time getting services someone needs when they refuse it) and social work is only wanted as a ‘pass on’ function to get services when your assets are low.

      I would dispense with safeguarding and social work involvement and create a single NHS staff run regime as many issues around elder health are really their remit.

      Finally, as someone with an effectively terminal illness, social workers are not fit to determine whether someones death was avoidable. I often suspect this, (health is my background), on visiting my relative in care home, but I also know in very old age / illness death occurs for many reasons. In younger people one might feel something went wrong that could have been avoided and question.

      I am sure social workers’ desire to develop roles in adult care related to safeguarding, (which is really the role of everyone in society), is fuelling the idea that they take on everything they think is a safeguarding matter. This the public will question when health issues are involved..

  9. Yvonne Bon if as October 21, 2014 at 12:28 pm #

    Edna needstodirect her ire further up the ladder. Social workers on the front line have virtually no choicein the cost and quality of services they direct people to. These days,
    commissioners reign supreme.

    Edna is I think right that complaints and safeguarding should be investigated by someone with the professional knowledge base. Otherwise there is the danger will be either neglect is missed or providers are unfairly blamed.

    • Edna October 23, 2014 at 9:34 am #

      Yvonne

      Rest assured I do raise concerns that I and many many others now, including older people, have with the the ‘state machinery’ controlling our lives by creating a ‘jobs industry’ for people who are not of thebhighest level of skills / education and hold views which allow control of others lives. Social workers in adult care are administrators in terms of controlling access to services (rather like GP’s who are increasingly criticised for failures, but at least they have extensive training in the relevant subjects backed by a very long held and extensive research base on large subject datasets).

      It is far easier to raise complaint against NHS staff. I have found social services complaints departments to be a self defending joke, This is why bad social work continues.