Pressure ulcer screening tool 
Report to be completed when determining if development of a pressure ulcer (category 
3 or 4) should lead to an adult’s safeguarding alert being made to Kirklees Council through West Yorkshire Safeguarding Adults Policy and Procedures	
This form should be completed by a registered nurse in line with 
your organisational policy	
Please store a copy of the form on the patient service user records	
The content of this report is confidential.  It should be shared with Kirklees Council if a safeguarding adult’s alert is made, in the best interests of the adult at risk.	
Name of patient/adult at risk:	     	
Normal address of patient/service user:	     	
DOB:	     	
Hospital Number/NHS Number:	     	
Place of current care:	     	
Previous place of care 
(if appropriate):	     	
GP or Consultant:	     	
Documentation available at time of reporting (please list):

	     
	
1.	Where is the location of the pressure ulcer(s)?
What category is the pressure ulcer (EUPAP 2009)?	
     

	
2. Has there been a recent change in medical condition e.g. infection, pyrexia, anaemia, end of life care, chronic disease, sensory/neurological deficit, that could have contributed to skin damage?	
Yes  		No		
Give details:       	
3.  Please indicate what Risk Assessment was used and the outcome (including risk assessment score/status and clinical judgement).  	
Does the score/risk status reflect the patient’s condition?  When was the latest score calculated?
     

4. Have the following steps been taken to prevent skin damage?  	
	Yes	No	Don’t know	
Was a risk assessment tool completed prior to ulceration?				
Was skin inspected with documentation prior to ulceration?				
Was appropriate equipment installed in an adequate time frame?				
Was a repositioning regime implemented and evidenced?				
Was written literature given to the patient on pressure ulcer prevention?				
Are there any identifiable barriers to preventing a pressure ulcer?				
Is the patient in an appropriate care setting that meets their needs?				
Comments:       

	
5. In your clinical opinion do you think that the development of the pressure ulceration was avoidable or unavoidable	
Avoidable 		Unavoidable		
Please give a rationale for your answer:       
	
6a) If pressure ulceration was avoidable make Alert into safeguarding giving details of:
•	Date adult’s safeguarding alert completed
•	Current risk assessment and appropriate pathways
•	Steps taken to manage the pressure ulcer(s) 	
     

	
6b) If pressure ulceration was unavoidable give rationale/recommendations for not referring into safeguarding:
•	Current risk assessment and appropriate pathways
•	Recommendations for practice/completion of RCA
•	Referrals to Clinical Governance	
     
	
Details  member of staff completing this assessment:	
Name:	     	
Title:	     	
Place of work:	     	
Qualifications:	     	
Signed:	     	
Date:	     	

Adapted from North Yorkshire County Council 
When completing the screening tool consider the evidence against the following criteria:

Patient history
•	whether rapid onset and deterioration to a severe ulcer
•	patient compliance with care plan/behaviour 
•	whether extensive damage in a low risk patient

Co-morbidity
•	medical history
•	chronic disease
•	palliative care
•	mental health issues

Care regime
•	poor quality care: standard of assessment and use of relevant policy and procedures to support care and appropriate documentation with a plan of care
•	whether appropriate equipment has been provided
•	evidence implementation of plan of care 
•	continence management: hygiene 
•	deterioration of appearance 
•	general indicators of care – e.g. clean nails, oral care 
•	inappropriate prevention and treatment regimes 
•	recurrent pressure ulcers 
•	evidence of risk management

Hydration and nutrition
•	evidence of intake monitoring 
•	fluid balance 
•	regular weighing (regular monitoring of weight)

Under/over use of medication
•	note appropriate use of sedation if patient is immobile for extended periods 
•	is pain assessed and managed

Contributory circumstances of pressure ulcers
•	detailed history of patient journey - e.g. environmental changes - change(s) in care setting(s) 
•	history of falls 
•	previous history of pressure ulcers 
•	carer involvement 
•	health and social care involvement